9  2  6  8     1 


IvKCa^URKS 


NERVOUS  DISEASES 


FROM    THE    STANDPOINT    OF    CEREBRAL    AND    SPINAL    LOCALIZATION, 

AND  THE  LATER   METHODS  EMPLOYED  IN  THE  DIAGNOSIS 

AND    TREATMENT    OF    THESE    AFFECTIONS. 


AMBROSE    L. /RANNEY,    A.M.,    M.D., 

Professor  of   the  Anatomy  and    Physiology    of   the  Nervous   System  in    the   New  York    Post-Graduate 
Medical  School  and   Hospital ;   Professor  of  Nervous  and   Mental   Diseases  in   the   Medical 
Department  of  the  University  of  Vermont ;  Late  Adjunct-Professor  of  Anatomy  in  the 
Medical  Department  of  the  University  of  the  City  of  New  York  ;   Member 
of  the  Neurological   Society  of  New   York;    Resident  Fellow  of  the 
New    York   Academy   of   Medicine;     Member  of  the    New 
York    County    Medical    Societj' ;    Author    of    "The 
Applied  Anatomy  of  the  Nervous   System," 
"Practical     Medical    Anatomy," 
"  Electricity    in    Med- 
icine," etc. 


PROFUSKLY   ILLUSTRATED    WITH    ORIGINAL    DIAGRAMS    AND    SKETCHES    IN    COLOR    BT    THE 

AUTHOR;     CAREFULLY     SELECTED     "WOOD-CUTS,     AND     REPRODUCED 

PHOTOGRAPHS   OF    TYPICAL   CASES. 


PHILADELPHIA : 
F.    A.   DAYIS,   PUBLISHER, 

1888. 


Entered  according  to  Act  of  Congress,  in  the  year  1888,  by 

F.  A.  DAVIS, 
In  the  Office  of  the  Librarian  of  Congress  at  Washington. 
All  rights  reserved. 


The  Medical  Bulletin  Printing  House, 
No.  1231  Filbert  Street, 
Phihidelphia. 


I  00 


1    DEDICATE    THIS    VOLUME 

TO    MY    FKIEND, 

ERRATA. 

Page  18.    Fig.  6.    Text.    For  sJiaded portions  iea.d  gray  And  7-ecl  masses. 
I'age  156.    25th  line.    For  mnsculo-sp inal,  read  iniisculo-spM'o7. 
Page  166.    26tli  line.    For  hyprocephalus,  read  hydrocephalus. 
Page  2-58.    No.  (5)  occurs  twice  in  the  diagram.    The  lower  (5)  should  be 
Page 350.    Under  the  "Functional  Diseases  of  the  Coed,"  read 
Disease  for  Tliomsoii's  Disease. 


(6). 
TIio>n.ien's 


m 

ft 


HIS   ORIGINAL    INVESTIGATIONS    RESPECTING    THE 

CAUSATION    AND   CURE   OP    FUNCTIONAL 

NERVOUS   DISEASES. 


.•55Jiv'9 


The  Medical  Bulletin  Printing  House, 
No.  1231  Filbert  Street, 
Philadelphia. 


10' 


1    DEDICATE    THIS    VOLUME 

TO    MY    FRIEND, 

GEORGE    T.    STEVENS,   M.D.,    Ph.D., 

AS    A    TKIBUTE    TO 
HIS    PERSONAL     INTEGRITY     AND     GENERAL     SCHOLARSHIP, 

AND,    ABOVE    ALL,   TO 

HIS   ORIGINAL    INVESTIGATIONS    RESPECTING    THE 

CAUSATION    AND   CURE   OF    FUNCTIONAL 

NERVOUS   DISEASES. 


;l'33v'9: 


PREFACE. 


Whatevek  of  merit  or  demerit  this  course  of  lectures 
may  possess  in  the  opinion  of  its  readers  or  critics,  it  must  be 
conceded  that  it  differs  radically  in  arrangement  and  plan 
from  others  published  upon  this  department  of  medicine. 

The  first  section  treats  of  those  facts  (anatomical,  physio- 
logical, and  pathological)  upon  which  the  science  of  cerebral 
and  spinal  localization  of  to-day  is,  of  necessity,  based. 

The  second  section  discusses  more  completely  than  most 
works  in  this  field  the  various  steps  which  should  be  taken 
by  an  aspirant  in  neurology  during  the  clinical  examination 
of  a  patient ;  and  the  deductions  which  may  be  drawn  from 
the  facts  thus  elicited.  In  many  instances,  authors  have 
given  a  very  incomplete  resume  of  this  field  or  have  omitted 
it  entirely. 

The  third  and  fourth  sections  treat  of  individual  diseases 
of  the  l)rain  and  sj)inal  cord.  Each  is  discussed  from  the 
clinical  standpoint  indicated  in  the  first  section,  viz.,  the 
Jocalizatlon  of  the  lesions  described,  as  well  as  the  recognition 
of  the  type  which  is  encountered. 

The  section  wliich  treats  of  "functional"  nervous  diseases 
will,  I  trust,  receive  the  careful  attention  it  deserves.  It 
comprises  a  full  resume  of  the  researches  of  Dr.  George  T. 
Stevens  respecting  the  bearings  of  "eye-defect"  and  "eye- 

(V) 


VI  PEEFACE. 

strain"  upon  the  causation  and  cure  of  these  imperfectly 
understood  conditions.  My  own  observations  in  this  fiehl 
have  been  quite  extensive.  They  lead  me  to  fully  indorse 
all  that  has  been  claimed  by  this  author.  I  can  bear  strong: 
testimony  to  the  value  of  the  new  methods  of  examination 
and  treatment  suggested  by  him  for  these  distressing  and 
obstinate  maladies.  Like  other  delicate  procedures,  they  can 
only  be  intrusted  to  skillful  hands,  well  versed  in  their 
intricacies  and  careful  in  respect  to  minute  details.  No 
other  treatment  has  ever  yielded  me  such  satisfactory  results 
in  severe  forms  of  epilepsy,  hysteria,  chorea,  neuralgia, 
headache,  insanity,  and  functional  visceral  derangements. 
As  no  drugs  were  em23loyed  by  me  in  many  of  these  cases, 
the  relief  obtained  must  be  attributed  solely  to  the  method 
of  treatment  referred  to. 

The  final  section  treats  of  electricity, — an  agent  which 
is  to-day  invaluable  in  n euro-therapeutics,  but  which  is 
seldom  if  ever  discussed  in  neurological  manuals.  To  this 
subject  the  author  has  given  much  attention  for  some 
years  past. 

A  glossary  of  neurological  terms  has  been  added,  in 
order  that  the  reader  may  not  grope  in  the  dark  when 
uncertain  respecting  the  meaning  of  a  word  which  is  new 
to  him. 

Much  time  has  been  devoted  to  the  condensation  of  the 
matter  presented  within  reasonable  limits.  To  deal  with 
an  extremely  difficult  and  somewhat  new  field  in  medicine 
in  such  a  way  as  to  bring  it  within  the  grasp  of  those  who 
have  devoted  little  or  no  attention   to  it,  and   at  the  same 


PEEFACE.  Vll 

time  to  avoid,  from  those  more  familiar  with  the  field,  the 
criticism  of  superficiality,  has  been  no  easy  task.  The 
author  does  not  exj)ect  that  his  attempt  will  prove  acceptable 
to  all.  An  experience  of  fourteen  years,  however,  in  teaching 
medicine  has  governed  the  author  in  the  presentation  of 
this  field  as  he  deems  most  wise. 

To  those  who  have  attended  the  author's  lectures,  deliv- 
ered from  year  to  year  before  his  classes  (either  in  the 
Medical  Department  of  the  University  of  the  City  of  New 
York,  the  New  York  Post-Graduate  Medical  School  and 
Hospital,  or  the  Medical  Department  of  the  University  of 
Vermont),  much  of  the  matter  here  contained  will  certainly 
be  familiar,  and  he  trusts  acceptable. 

The  labor  of  preparing  this  volume  from  scattered 
lecture-notes  has  been  greater  than  might  appear  on  a  cursory 
examination.  Many  of  the  illustrations  are  from  the  author's 
pencil,  while  others  are  from  original  photographs  of  his 
cases.  Most  of  the  colored  diagrams  incorporated  are 
similar  to  those  drawn  by  him  upon  the  blackboard  before 
his  classes.  Colors  are  of  great  service  in  making  a  diagram 
clear  and  easy  of  comprehension.  To  the  author's  mind, 
diagrams  in  this  special  field  of  medicine  are  of  greater 
utility  to  the  busy  practitioner  than  microscopic  sections, 
because  very  intricate  mechanisms  are  discussed  and  inter- 
preted which  cannot  always  be  shown. 

Portions  of  this  work  embody  extracts  from  two  chapters 
upon  Diseases  of  the  Brain  and  Spinal  Cord  in  the  third 
edition  of  the  author's  treatise  on  "  Surgical  Diagnosis." 
Some  other  portions   have  appeared  in  print  from  time  to 


VUl  PEEFACE. 

time,  in  tlie  following  journals:  Neiv  York  Medical  Journal, 
Medical  Becord,  ArcJdves  of  Medicine,  Journal  of  Nervous  and 
Mental  Diseases,  Medical  News,  Harper^s  MontJdi/,  Medical 
Bidletin,  and  Medical  Register. 

In  closing,  the  author  would  acknowledge  his  gi*eat 
indebtedness  to  the  original  investigations  of  those  who 
by  their  researches  have  been  the  source  of  much  valuable 
information  incorporated  by  him  in  this  work.  This  ac- 
knowledgment must  act  as  a  poor  substitute  for  frequent 
reference-notes,  which  are  precluded  on  account  of  a  want 
of  space.  A  bibliography  of  some  of  the  more  important 
works  and  monographs  on  this  field  to  which  the  author  is 
indebted  is,  however,  appended  for  the  benefit  of  the  reader. 
Special  care  has  been  exercised  in  selecting  these,  as  far 
as  possible,  from  sources  which  are  easily  accessible  to 
American  readers. 

AMBROSE  L.  RANNEY,  A.M.,  M.D. 

156  Madison  Avenue, 

New  York  City,  May,  1888. 


TABLE  OF  CONTENTS. 


SECTION  I. 

ANATOMICAL,  PHYSIOLOGICAL,  AND  PATHOLOGICAL  DEDUC- 
TIONS  RESPECTING   THE   NERVE-CENTEES    OF   MAN,  .  .  1 

SECTION  II. 

THE  CLINICAL  EXAMINATION  OF  PATIENTS  AFFLICTED  WITH 
NERVOUS  DISEASES,  AND  THE  STEPS  EMPLOYED  AS 
AIDS    IN   DIAGNOSIS, 107 

SECTION  III. 

DISEASES    OF   THE   BRAIN   AND    ITS   ENVELOPES,         .  .  .      217 

SECTION  IV. 

DISEASES    OF   THE   SPINAL    CORD   AND    ITS   ENVELOPES,     .  .      347 

SECTION  V. 

FUNCTIONAL   NERVOUS   DISEASES, 449 

SECTION  VI. 

TOXIC   AND    UNCLASSIFIED   NERVOUS   DISEASES,  .  .  .      555 

SECTION  YII. 

ELECTRICITY   IN   MEDICINE, 605 

GLOSSARY   OF   NEUROLOGICAL   TERMS, 745 

BIBLIOGRAPHY, •  753 

INDEX, 763 


(ix) 


LIST   OF   ILLUSTRATIONS. 


Fig.    1.— Diagram  of  rompotient  part';  of  Brain, 

2. —         ••         "  Cortical  ("ell,    . 

■i. —         "         "  Cortical  Centres, 

4.—         "         "  Cerebral  Convolutions,  . 

5. —         "         "  (Cortical  Area.s, 

().—         "         "  Cerebral  Fibres, 


"         "  Centres  of  Tlialanms, 
-Section  of  Cerebral  Hemispheres, 


-Diagram  of  the  Crura  Cerebri, 

"         "  Fibre-Tracts  of  Brain  and  Cord, 

-Section  through  the  Pons,   .... 

-Diagram  of  the  Fibre-Tracts  of  Cerebellum, 
"  Medulla, 
"  "        Nuclei  of  the  Medulla,    . 

"  "        Fibre-Tracts  of  the  Spinal  Cord, 

"  "        Pyramidal  Fibres  of  Medulla, 

"  "       Nerve-Tracts  of  Spinal  Cord, 

"  "        Motor  Centres  of  Cerebrum, 

"  "        Optic  Fibres,      .... 


"  "       Cerebral  Mechanism  of  Speech, 

"        of  Motor  and  Sensory  Cerebral  Tracts, 

-Base  of  Cerebrum  (partial),        .... 

-Diagram  of  a  Cross-Section  of  the  Medulla,  . 

-Base  of  Skull  and  Cranial  Nerves,    . 

-A  Diagram  of  Fibre-Tracts  of  Spinal  Cord,    . 

-A  Spinal  Segment, 

-Diagram  of  Relations  of  Spinal  Segments  to  Vertebrae 
"         "  Fibre-Tracts  of  Spinal  Cord, 
"         "  Spinal  Gray  Substance, 

"         "a  Reflex  Arc, 

"         "  Cei'el)ro-Si)inal  Architecture, 

-Scheme  of  Cerebro-Spinal  Nerve-Tracts, 

-Diagram  of  Refractive  Errors  of  Eye, 

"         "  Ciliary  Action,  .... 

-The  Ophthalmoscope, 

-Sketch  of  Facial  Paralysis,  .... 

-Syphilitic  Teeth 

-The  Claw-hand 

-Ulnar  Paralysis, 

-iNIediau  Paralysis  (two  views),    .... 

-Musculo-Spiral  Paralysis, 

-Athetosis 

-Paralysis  Agitans, 

-Pseudo-hypertrophic  Paralysis, 


KCK  OF  IMATSTRATIONS.      PAGE 

Original.  5 

Muilijicd/rom  Liiyx.  7 

"  "      I'^rrrirr. 

"  "     Dullon. 

Original. 


Mudifiedfrom  Litps. 

"  •■      Flcehaig. 

"  "      Schucfer. 

Original. 

Modified froi'i  Erb. 
Original 
Modified  from  Erb. 

Original. 
Modified  from  Erb. 

"  "     Fleehsig. 

Original. 


Modified  from  Segu  in. 

Original. 

Modified  from  Spltzka. 

Oi  iginal 

Modified  from  Bramirell. 

Original. 

Modified  from  Gowers. 

"  "     Bramwell. 

"      Erb. 

"  "      Bramwell. 

"  "     Ferrier. 

Aeby. 

Original. 

Modified  from  Fick. 

Loriiig. 

Original. 

Iliitehinson. 

Original. 

Modified  from  Bramtvell. 

Original. 


Modified  from  Hammond. 
"  "      Chnri-ot. 

"  "      Di<eli<n7ic. 

"  "      Gotvers. 

Xl  1 


10 

12 

14 

IS 

21 

23 

24 

26 

32 

34 

36 

38 

42 

42 

45 

45 

47 

54 

67 

58 

69 

67 

71 

74 

7,S 

79 

S7 

Sit 

<J() 

<)2 

!t4 

95 

97 

102 

103 

125 

127 

149 

152 

154 

15(i 

157 

15S 

159 

161 

Hi:; 

101 

167 


Xll  LIST   OF   ILLUSTRATIONS. 

SOURCE  OF  ILLITSTRATIONS.      PAGE 

Fig.  51.— Pseiulo-hypertrophic  Paralysis, Modified  from  Gowers.         107 

"    52.—        "         '         "                  .'            "             "           "  167 

"     53.-        "                  "                  "            "             "           "  167 

"    54.— Attitude  from  Atrophy  of  Back  Muscles,        ...  "             "     Duchenne.     168 

"     55.—        "            "            "          "  Abdouiiual  ^luscles,    .        .  "             "           "  169 

"     56.— Dynamometer, Instrunient-niaker.  177 

"     57. — Dynamograiih "               "  178 

"    58.— Curves  of  Polar  INIuscular  Contraction  (three  cuts),    .  Erb.  188 

"     59.— Author's  Spring  Electrode, Original.  191 

"     60.—        "         Diagnostic  Key-board, "  192 

"     61.—        "                   "                  "           (inaction),    ...  "  193 

"     62.— Electrode Erb.  198 

"     63.— Piesmeter, Beard.  199 

"     64.- ^Esthesiometer, Hammond.  200 

"     65.—              "                    Carroll.  201 

"     66.—              "                    Sieveking.  201 

"     07.— Diagram  of  Effects  of  an  I^nilateral  Spinal  Lesion,      .  Modified  from  Erb.  205 

"     68. —         "         "  Relations  of  Certain  Cranial  Nerves,        .  Orif/inal.  207 

"     69.—         "         "           "          "  Optic  Nerves,   ....  Modified  from  Segnin.          209 

"     70.— Surface  Thermometer, Seguin.  210 

•'     71.— Differential  Thermo-Electric  Calorimeter,      .        .        .  Iivitrument-maker.  211 

"     72. — Duchenne"s  Trochar, "               "  212 

"     73.— Miliary  Aneurism  of  the  Cerebral  Cortex,      .        .        .  Van  Schaick.  220 

"     7-1. — Diagram  of  Cerebral  Sinuses  in  Pi-ofile,          .        .        .  Original.  225 

"     75. —         "         "  the  Venous  Sinuses  of  the  Dura-Mater,    .  "  226 

"     76.—         "         "  an  Embolic  Infarction, Modified  from  Weber.  230 

"  77. —  "  "  the  JNIechanism  of  the  Speecli  Aiiparatus,  Original.  235 
"     78. —         "         "  a  Transverse  "X'ertical  Section  of  the  Left 

Cerebral    Hemisphere,   showing    the  Arterial 

Distribution, Modified  from  Westbrook.    242 

"     79.— Diagram  of  the  Effects  of  Cortical  and  Non-Cortical 

Lesions  of  the  Cerebrum, Original.  255 

"     80. — Diagram    of    the    Motor   Tracts   and  the  Effects  of 

Lesions  of  the  Cms  Cerebri,  Pons  Varolii,  and 

ISIeduUa  Oblongata  upon  Motility,  .  .  .  Modified  from  SUn-r.  258 
"     81. — Diagram  of  the  Sensory  Tracts  and  the  Effects  of 

Lesions  involving  tlie  same  within  the  Cms 

Cerelni  and  the  Medulla  Oblongata,  ...  "  "  «  2.59 
"     82. -diagram  of  a  Horizontal  Section  through  the  Cerebral 

Hemispheres  and  the  Basal  Cianglia,  .  .  .  Original.  268 
"     83.— One  of  the  Attitudes  of   a  Hand  caused   by  Post- 

Hemiplegic  Contracture, "  270 

"     84.— Chronic  Hydrocephalus, "  313 

"    85.— Softened  Brain-Tissue, Modified  from  Eox.  318 

"     86.— The  Fundus  of  the  Normal  Eye, Jioxs.  322 

"     87. — The    Appearance    of    the    Fundus    of    the    Eye    in 

"Choked  Disk," "  322 

"    88. — Cerebral  Sclerosis, Modified  from  Fox.  332 

"     89.— Cerebral  Glioma "             .;        >.  339 

"     90.— Syphilis  of  the  Brain "             "        '•  340 

"  91. — Diagram  of  Nerve-Fibre  Ti-acts  in  the  Spinal  Cord,  .  "  "  Flechsig,  351 
"     92. —         "         "  the  Secondary  Effects  of  a  Lesion  of  the 

Entire  Spinal  Cord, Erb.  354 

"     93. — Diagram  to  show  Distribution  of  Crossed  Pyramidal 

Fibres  to  Sjjinal  Segments, Original.  358 

"     94. — Diagram  of  the  Secondary  Sclerosis  following  a  Lesion 

of  the  Left  Cerebral  Hemisphere,        .        .        .  Erb.  362 

"  95. — Diagram  of  Multiple  Spinal  Sclerosis,  .  .  .  .  "  363 
"     96. — Case  of  Poliomyelitis  Anterior,  followed  by  Extensive 

Atrophy  of  Right  Side, Original.  366 

"     97.— Case  of  "Wing-Scapula,""  from  Atrophy  of  Muscles,  .  "  367 

"    98.— Profile  View  of  same  case,  showing  Atrophy  of  Deltoid,  "  368 


LIST   OF   ILLUSTRATIONS. 


Xlll 


Fig 


flO. 
100. 
101 

103. 
104. 
105. 


100. 
110. 
111. 
112. 
113. 
114. 

115. 

116. 

117. 
118 

120, 


121. 
122, 
123, 
124 
125 
120, 
127, 
128, 
120. 
130. 
131. 
132. 
133. 
1.34. 
135. 


SOtJHOE  OF  ILLUSTKATIONS. 

— Poliomyelitis  Anterior  Acuta, Origiiial. 

— Full  View  of  same  cat'c,  showing  the  Atrophy  of  Hand,  " 

and  102. — A  Case  of  Infantile  Paralysis,  with  Involve- 
ment of  the  Mi-diillary  Nuclei,      ....  " 

— Hand  in  Amyotrophic  Ijateral  Sclerosis, 

— Fibres  from  the  Diaphragm  in  Health,  .... 

— Same  taken  from  a  Case  of  Progressive  Muscular 
Atrophy  affecting  the  I)iai)hragm, 

— Two  Views  of  the  Hand  of  a  Patient  suffering  from 
Progressive  Muscular  Atrophy 

— Progressive  Muscular  Atrophy  of  all  the  Limbs, 

— Expression  due  to  Implication  of  the  Nuclei  of  the 
Medulla  governing  the  Mouth,  Tongue,  and 
Throat, Hammond. 

—Profile  of  Patient  similarly  affected,       ....  " 

— Hemiatropliy  of  the  Face, 

—  "  "  Tongue  and  Palate,        .... 

—Side  View  of  Pseudo-Hypertrophic  Paralysis, 

— Rear    "       "        "  "  "  .        . 

— A  Diagram  of  the  Lesion  of  the  Sensitive  Tracts  in  an 
Unilateral  Lesion  of  the  Right  Side,    . 

— A  Transverse  Section  of  the  Spinal  Cord  of  an  Ataxic 
Patient, 

—A  Diagram  of  the  Pathological  Lesion  of  the  Cord 
observed  in  Locomotor  Ataxia,    .... 

— Extensive  Joint-Changes  in  Locomotor  Ataxia,  . 

and  110.— "Charcot's  Disease"  of  Left  Knee-Joint  fol- 
lowing Locomotor  Ataxia, 

, — Cavities  within  the  Substance  of  the  Spinal  Cord, 
con.stituting  the  condition  known  as  "Syringo- 
myelia,"        

— Hystero-Epilepsy, 

,— Another  Attitude  of  same  case, 

—Third  ..         u        u        u 

.—Convulsion  of  Hystero-Epilepsy, 

—Case  of  Catalepsy, 

—A  Cataleptic  Patient,  supported  by  Head  and  Feet,   . 

— A  Marked  Paroxysm  of  Tetanus, 

, — Paralysis  Agitans,  or  Shaking  Palsy 

—Morbid  Appearances  presented  in  Hereditary  Ataxia, 

— Photograph  of  Case  of  Ataxia,         .        . 

—Second  Photograph  of  Case  of  Ataxia,  .... 

—Section  of  Dorsal  Region  of  Spinal  Cord, 


Charcot. 


Orif/inal. 
Friedreich. 


Original. 
Duchenne, 

Erb. 

Van  Schaick. 

Erb. 
Charcot, 


Original. 


Mills. 


Original. 

Bell. 
Charcot. 
Friedreich. 
Smith. 


136 
137. 
138, 
139 


140. 
141. 
142. 
U:i. 
144. 
145. 
146, 
147, 
148. 


One  of  the  Many  Forms  of  Faradaic  Machines,  .        .    Instrument-maker. 

Diagram  of  the  Construction  and  Action  of  a  Fara- 
daic Machine, Original. 

—A  Static  Machine  in  Use, Instrument-inaker. 

—A  Simple  Galvanic  Element, Erb. 

— A  C(mipound  Chain, " 

— A  Schematic  Representation  of  the  Introduction  of  a 
Human  Body  into  the  Circuit  of  Closure  of  a 
Galvanic  Chain, " 

Six  Cells  Connected  for  Intensity, De  WatteviUe. 

—  "        "  "  "    tiuantity, " 

— Smee's  Cell, Instrument-maker. 

Leclanche's  Cell " 

.— Grenet's  Cell, " 

,— Fuller's  Cell 

. — Siemens  and  Halske's  Cell, " 

.—Hill's  Gravity  Cell, " 

— Grove's  Cell, " 


FAGK 
3(i0 
370 

373 
377 
380 

380 

382 
383 


384 
385 
o80 
386 
389 
389 

391 

392 

397 
399 

402 


43.1 
511 
512 
513 
513 
514 
515 
582 
589 
591 
592 
593 
594 
595 
<J10 

fill 
<il2 
614 
619 


620 
621 
621 
623 
624 
624 
625 
625 
626 
626 


XIV  LIST   OF   ILLUSTRATIOXS. 

SOURCE  OF  ILLUSTRATIOXS.      PAOK 

Fig.  149.— Bunsen's  Cell, Inslrianent-maker.                 627 

"    loO. — A  Galvanometer  Dial, De  Walleville.                          62» 

"    151.— A  Diagram  of  the  ;Metho(l  of  Tangent  Calibration,      .  Original.                                   629 

"    152. — A  Horizontal  Millianipere-meter, Inslrument-tnakcr.                 629 

"    153. — "  Dead-beat "  Milliampere-meter, "               "                        6:^0 

"    154.— A  Fluifl  Rheostat "               "                        631 

"    155.— Rosebrugh's  Fluid  Rheostat, Canada  Pract.                        632 

"    156. — Thermo-Electric  Differential  Calorimeter,    .        .        .  Inislrument-muker.                 6.33 

"    157. — A  New  Form  of  Current  Selector, "               "                        6.34 

"    158. — A  Skeleton  Drawing  of  the  Pin  Variety  of  Portable 

Galvanic  Battery, "               "                        635 

"    159. — Various  F^orms  of  Electrodes, Erh.                                           637 

"    160. —        "           "        "  Special  Electrodes,     ....  Instrument-maker.                 6:iS 

"    161. — The  Physician's  Handy  Cabinet  Batteiy,       .        .        .  Original.                                   640 

"    162. — The  Perfected  Oflfice  Cabinet  Battery,    ....  Instrument-maker.                 642 

"    163.—  "             "          Wall  Cabinet Original.                                   644 

"    164. — Hawksbee's  Original  Electi-ical  Machine,      .        .        .  JVollct.                                        647 

"    165. — Ramsden's  Electrical  Machine, Appleton  &  Co.                         648 

"    166.— Nairne's             "                 "                 i.           u                              (j49 

"    167. — Nicholson's  "  Electric  Doubler," New  Royal  Encyclop.  of 

Arts  and  Sci.  650 

"    168. — .Same  machine, Neiv  Royal  Encyclup.   of 

Arts  and  Sci.  650 

"    169. — An  Apparatus  for  Generating  Frictional  Electricity 

by  Steam, Armstrong.                              651 

"    170. — Old  Model  of  Cylindrical  Static  Machine,      .        .        .  Nciv  Royal  Encyclop.  of 

Arts  and  Sei.  651 

"    171. — Holtz's  Induction  ^Machine, Appleton  &  Co.                        652 

"    172. — Stationary  Plate  of  the  Original  Holtz,  ....  "           "                              653 

"    173. — Holtz's  Static  Induction  Machine, "           "                              6-54 

"    174. — Improved  Holtz  Induction  Machine,       ....  Original.                                   6-57 

"    175. — Electrodes  Employed  with  an  Induction  Machine,       .  Instrument-maker.                  662 

"    176.— The  Indirect  Spark, Original.                                  666 

"    177.— The  Direct  Spark, '•                                            668 

"    178. — Shock  with  Leyden-Jar  Discharge, "                                            669 

"    179. — An  Application  of  the  Leyden-Jar  Shock  during  the 

Eighteenth  Century, Neiv  Royal  Encyclop.  of 

Arts  and  Sci.  669 

"    180. — Static  Insulation, Original.                                   670 

"    181. — The  Indirect  Static  Breeze, "                                         671 

"    182.— The  Direct          u           u              ^■.                                           671 

"    18;?.— The  Electrical  Head-Bath, "                                            672 

"    184.— The  Static  Induced  Current, "                                            673 

"    185.- Morton's  Pistol-Electrode, Instrument-m.aker.                  674 

"    186.— Electrode  for  Electrolysis, "               "                        694 

"    187. — An  Electrode  for  Electrolysis, "               "                        694 

"    188.— Piffard's  Cautery  Battery, "               "                        698 

"    189.— Schematic  Representation  of  the  Distribution  of  an 

Electric  Current  apirtied  Unilaterally  to  the 

Head Erb.                                            714 

"    190. — Schematic  Representation  of  the  Course  of  Electric 

Currents  sent  Transversely  through  the  Head,  "                                                714 
"    191. — Schematic   Representation   of  the  Distril)ution  and 

Density  of  Threads  of  Electric  Currents  during 

Applications  to  the  Spinal  Cord,  .        .        .        .  "                                                716 
"    192. — Schematic  Representation  of  the  Density  of  the  Cur- 
rent upon  Application  of  the  Electrodes  to  the 

same  Surface  and  in  Close  Relation  to  Each 

Other, "                                             717 


SECTION  I. 


ANATOMICAL,    PHYSIOLOGICAL,   AND    PATHOLOGL 

CAL  DEDUCTIONS  RESPECTING  THE 

CEREBRO-SPINAL  AXIS 

OF  MAN. 


SECTION  I. 

ANATOMICAL,     PHYSIOLOGICAL,     AND     PATHOLOGICAL     DEDUCTIONS 
RESPECTING   THE   CEREBRO-SPINAL   AXIS   OF   MAN.* 

Some  thirt^'-six  years  ago,  by  a  premature  explosion  of  gunpowder, 
an  iron  bar  three  and  a  half  feet  long,  one  and  a  quarter  inches  in  diameter, 
and  weighing  thirteen  and  a  quarter  pounds,  was  shot  completely'  through 
a  man's  head  and  perforated  his  brain.  This  man  walked  up  a  flight 
of  stairs  after  the  accident,  and  gave  his  account  of  how  it  happened. 
Although  his  life  was  naturall}-  despaired  of  for  some  time,  he  developed 
no  paralysis,  nor  did  marked  impairment  of  his  intellectual  faculties 
follow  convalescence.  Eventually  he  recovered  his  health.  Twelve  years 
elapsed  before  his  death;  during  which  time  he  worked  as  a  laborer  on 
a  fiirm. 

The  "American  crowbar  case"  at  once  became  famous.  It  startled 
the  minds  of  the  reading  public,  and  confounded  the  medical  fraternity. 
Xo  satisfactory  explanation  of  the  remarkable  features  of  the  case  could 
be  given.  Some  prominent  medical  men  pronounced  it  ''  an  American 
invention,"  and  laughed  at  the  possibility  of  such  an  occurrence.  The 
skull  was  exhumed,  however,  after  death,  and  is  to-day  in  the  medical 
museum  of  Harvard  University. 

This  case  may  be  said  to  have  been  the  starting-point  of  a  new  epoch 
in  medical  science.  It  rendered  untenable  all  previous  hypotheses  that 
had  been  advanced  regarding  the  organ  of  the  mind.  It  proved  con- 
clusively that  little,  if  anything,  was  known  at  that  time  respecting  the 
architecture  of  the  brain  of  man,  and  the  functions  of  its  component 
j)arts. 

Since  then,  a  large  number  of  observers  have  published  the  results 
of  various  forms  of  experiments  upon  animals,  made  with  a  view  of  deter- 
mining the  plu'siologT  of  the  brain  ;  but  for  some  years  the  conclusions 
drawn  from  such  investigations  were  contradictory,  and  nothing  was 
definitely  established. 

We  now  are  aware  that  serious  defects  existed  in  the  early  methods 
of  research.  B}'  great  ingenuity  these  have  been  gradually  eliminated. 
We  owe,  however,  to  the  discoveries  of  Tiirck,  Fritsch  and  Hitzig. 
Waller,  Flechsig,  and  Gudden,  most  of  our  knoM-ledge  of  new  methods 

*The  first  ten  pages  of  this  chapter  are  quoted  (with  many  important  modiflcations 
and  additions)  from  an  article  contributed  by  the  author  to  Harpers  Monthly,  March, 
1885. 

1 


2  LECTURES   ON   NEEVOUS   DISEASES. 

of  research  which  have  simplified  the  stud}'  of  the  nervous  system  during 
life  and  after  death.  These  methods  of  investigations  have  settled  many 
points  in  dispute.  They  have  also  made  our  knowledge  more  accurate, 
and  in  accord  with  clinical  observations. 

The  last  decade  has  enabled  us  to  bring  many  of  the  results  obtained 
by  vivisection  into  perfect  harmony  with  pathological  data.  Those  who 
have  claimed  that  conclusions  drawn  from  experiments  upon  animals  are 
not  applicable  to  man  are,  to-day,  confronted  with  certain  unanswerable 
facts  to  the  contrary.  Nature,  through  the  agency  of  disease  processes, 
is  constantly  performing  experiments  upon  human  brains;  and  the  symp- 
toms so  produced  ma}'  be  recorded  during  life,  and  compared  with  the 
changes  found  in  the  brain  after  death.  Physiology  and  pathology  have 
thus  proven  valuable  lines  of  research  in  this  field  * 

To-day,  the  "  crowbar  case  "  is  no  longer  a  mystery  to  specialists 
in  neurology.  Bullets  have  been  shot  through  the  brain  since  then 
without  loss  of  motion,  sensation,  or  intellect;  and,  in  some  cases,  they 
have  been  known  to  remain  buried  in  the  brain  substance  for  months 
without  apparent  ill  eflfects.  Five  years  ago  a  breech-pin  of  a  gun,  four 
and  three-quarter  inches  long,  was  forced  into  the  brain  of  a  boy  nine- 
teen years  old,  through  the  orbit,  and  its  presence  was  not  suspected 
for  some  five  months.  It  was  discovered  during  a  surgical  attempt  to 
repair  the  facial  deformity  that  resulted  from  the  accident.  Death  fol- 
lowed the  removal  of  the  foreign  body  from  the  brain  in  consequence  of 
inflammation  created  by  the  piece  of  iron,  or  possibly  by  its  extraction. 
This  case  is  quite  as  remarkable  as  the  crowbar  case,  but  it  excited  less 
interest  in  neurological  circles  because  we  are  in  possession  of  new  facts. 

We  know,  to-day,  that  if  even  a  needle  be  thrust  into  one  region  of 
the  brain  (the  medulla  oblongata.  Fig.  1),  immediate  death  may  follow; 
while  a  crowbar  may  traverse  another  portion  of  the  organ,  and  recover}'' 
be  possible.  The  effects  of  injury  to  the  brain  depend  rather  upon  its 
situation  than  its  severity. 

In  the  light  of  our  present  knowledge  the  brain  must  be  regarded 
as  a  composite  organ;  whose  parts  have  each  some  special  function,  and 
are,  to  a  certain  extent,  independent  of  each  other. 

*  There  are  at  the  present  time  three  distinct  schools  among  the  experimental  phy- 
siologists respecting  the  subject  of  cerebral  localization.  Ferrier  and  Munk  represent  a 
faction  which  strenuously  hold  the  view  that  the  cortical  gray  substance  can  be  mapped 
out  into  areas  whose  limits,  as  well  as  their  individual  functions,  are  clearly  defined. 
Goltz  stands  at  the  head  of  a  school  which  denies  the  accuracy  of  these  views,  and  supports 
the  conclusion,  originally  advanced  by  Flourens,  that  the  brain  can  only  act  as  a  whole. 
Exner  and  Luciani  (in  common  with  their  followers)  occupy  a  ground  which  opposes  verj- 
sharply-defined  boundaries  to  cortical  areas,  functionally  associated  with  the  various  senses. 
They  believe  that  these  areas  overlap  each  other  to  a  greater  or  less  extent.  At  present, 
the  latter  view  seems  to  be  most  perfectly  in  accord  with  clinical  and  oathological  data. 


THE   CEREBRO-SriNAL   AXIS    OF   MAN.  3 

One  limited  part  is  essential  to  A'ital  processes  ;  hence  its  destruction 
causes  death.  Another  part  presides  over  the  various  movements  of  the 
body  ;  hence  paralysis  of  motion  is  the  result  of  destruction  of  any 
portion  of  this  area.  A  third  part  enables  us  to  appreciate  touch,  tem- 
perature, and  pain  ;  and  some  disturbance  of  these  functions  will  be 
apparent  when  this  region  is  injured  or  diseased.  A  fourth  regioa  pre- 
sides over  sight ;  disturbances  of  vision  may  follow  disease  or  destruction 
of  this  area,  in  spite  of  the  fact  that  the  eyes  escape.  In  the  same  wa}-, 
smell  and  hearing  are  governed  by  distinct  portions  of  the  brain,  and  also 
the  sense  of  taste.  When  a  combined  action  of  different  parts  is  demanded 
— as  in  the  exercise  of  the  reason,  judgment,  will,  self-control,  etc. — the 
knowledge  gained  by  means  of  the  special  senses  can  be  contrasted  and 
become  food  for  thought. 

The  skilled  neurologist  can  determine  to-day,  in  many  cases,  by  the 
symptoms  exhibited  during  life,  the  situation  and  extent  of  disease  pro- 
cesses that  are  interfering  with  the  action  of  certain  parts  of  the  brain. 
So  positive  is  the  information  thus  atforded,  in  some  cases,  that  surgical 
operations  are  now  performed  for  the  relief  of  the  organ.  A  patient 
who  had  lost  the  power  of  speech  from  an  accumulation  of  pus  within 
the  brain,  was  latel}-  cured  b>'  the  removal  of  a  button  of  bone  from  the 
skull  over  the  seat  of  the  pus,  and  its  prompt  evacuation.  Epileptics 
who  suffer  in  consequence  of  brain-irritation  may  sometimes  be  cured  of 
their  fits  by  the  mechanical  removal  of  the  cause.  Paralysis  can  occa- 
sionally be  alleviated  by'a  removal  of  blood  or  pus  from  the  surface  of  the 
brain  through  a  hole  in  the  skull.  Only  a  few  months  ago  a  bullet,  whicli 
had  been  shot  into  the  head  during  an  attempt  at  suicide,  was  removed 
from  the  skull,  in  one  of  our  hospitals,  by  means  of  a  counter-opening. 
The  labors  of  such  men  as  Meynert,  Notlmagel,  Ferrier,  Flechsig,  Wer- 
nicke, Munk,  Luciani,  Exner,  Charcot,  and  others,  have  made  neurology 
a  science  that  would  exceed  the  comprehension  of  its  founders.  Our 
ability  to  localize  disease  within  the  substance  of  the  spinal  cord  is  even 
more  positive  than  in  the  case  of  the  brain. 

When  we  consider  that  it  is  b}'  means  of  our  nervous  system  that  we 
move,  feel,  see,  hear,  smell,  taste,  talk,  and  swallow ;  that  in  our  brains 
are  stored  all  the  memories  of  past  events;  that  we  digest  and  assimilate 
our  food  partly  by  the  aid  of  nerves  ;  and  that,  in  fact,  we  perform  every 
act  of  animal  life  by  the  same  agency, — the  utility  of  the  latest  infor- 
mation regarding  the  brain  becomes  apparent  at  once. 

The  nerves  are  but  telegraphic  wires  that  put  the  brain  and  spinal 
cord  in  direct  communication  with  the  muscles,  the  skin,  and  the  various 
organs  and  tissues  of  the  body. 

The  nervous  centres  may  therefore  be  compared  to  the  main  offices 
of  a  telegraphic  system,  where  messages  are  being  constantly  received 


4  LECTURES   ON   NERVOUS   DISEASES. 

and  dispatched.  Every  message  sent  out  is  more  or  less  directlj'  the 
result  of  some  message  received.  So  it  is  with  our  nerve  centres.  We 
are  constantly  in  receipt  of  impressions  of  sight,  smell,  taste,  hearing, 
touch,  and  other  conscious  sensations.  These  are  called  afferent  im- 
pulses. As  the  result  of  the  information  so  gained,  we  are  constantly 
sending  out  efferent  or  motor  impulses  to  the  muscles.  These  create 
movements  of  different  parts  of  the  body.  Respecting  this  view,  Michael 
Foster  expresses  himself  as  follows:  "All  daj^  long,  and  ever}-  day,  mul- 
titudinous afferent  impulses,  from  eye,  and  ear,  and  skin,  and  muscle, 
and  other  tissues  and  organs,  are  streaming  into  our  nervous  system  ; 
and  did  each  afferent  impulse  issue  as  its  correlative  motor  impulse, 
our  life  would  be  a  prolonged  convulsion.  As  it  is.  by  the  checks 
and  counter-checks  of  cerebral  and  spinal  activities,  all  these  impulses 
are  drilled  and  marshaled  and  kept  in  hand  in  orderly  array  till  a  move- 
ment is  called  for ;  and  thus  we  are  al)le  to  execute  at  will  the  most  com- 
plex bodily  manoeuvres,  knowing  onh*  xohij,  and  unconscious  or  but  dimh' 
conscious  hoii\  we  carry  them  out." 

Sometimes,  however,  the  motor  Impulses  sent  out  by  the  brain  in 
response  to  sensory  impressions  take  place  in  spite  of  our  volition.  Let 
us  cite  an  instance  in  the  wa}'  of  illustration :  a  timid  person  sees  per- 
chance some  accident  in  which  human  life  is  possibly  sacrificed,  or  the 
sensibilities  are  otherwise  shocked.  His  feelings  overcome  him,  and  he 
faints.  How  are  we  to  explain  it?  Let  us  see  what  takes  place.  The 
impression  upon  the  brain  made  by  the  organ  of  sight  creates  (through 
the  agency  of  special  centres  in  the  organ  of  the  mind)  an  influence  upon 
the  heart  and  (by  means  of  vaso-motor  nerve  filaments)  upon  the  blood- 
vessels of  the  brain.  This  results  in  a  decrease  in  the  amount  of  blood 
sent  to  the  brain,  and  causes  a  loss  of  consciousness.  In  the  same  way 
persons  become  dizzy  when  looking  at  a  water-fall,  or  from  a  height, 
through  the  effects  of  the  organs  of  sight  upon  the  brain. 

Again,  if  a  frog  be  deprived  of  only  the  upper  part  of  the  cerebral 
hemispheres,  he  is  still  capable  of  voluntar}'  movement,  breathing,  swallow- 
ing, croaking,  and  all  the  other  manifestations  of  frog-life.  But  when  we 
observe  such  an  animal  with  attention,  we  shall  see  that  he  is  only  a  pure 
automaton,  and  that  he  differs  from  the  normal  frog  in  his  behavior  when 
left  to  himself  and  when  disturbed.  He  will  swim  when  placed  in  water, 
but  only  until  he  reaches  a  spot  where  lie  can  safely  repose.  Then  lie  re- 
lapses into  quietude,  evincing  no  desire  to  hop  (as  a  normal  frog  would 
do)  or  to  escape  from  his  tormentor.  Every  time  that  his  back  is  stroked 
the  frog  will  croak.  The  same  irritation  will  produce  the  same  result 
over  and  over  again.  Such  a  frog.,  if  placed  upon  a  board  which  can  be 
tilted,  will  climb  up  the  board  (in  case  he  perceives  that  his  equilibrium 
is  endangered)  in  a  direction  necessary  to  render  his  position  secure. 


THE   CEREBRO-SPINAL   AXIS   OF   MAN. 


Otherwise  he  remains  motionless.  He  is  no  Ioniser  a  frog  endowed  with 
the  normal  attributes  of  that  animal  in  health.  He  does  not  attempt  to 
escape.  He  experiences  no  apparent  alarm  at  surrounding  objects.  His 
movements  can  be  predicted  and  repeated  again  and  again  at  the  will  of 
the  experimenter.  He  has  been  transformed  into  a  machine  in  which 
every  muscular  movement  can  be  traced  directly  to  some  stimulating 
influence  from  without.* 

C08TEX  OFPARigj 


Fig.  1. — A  Diagram  Designed  by  the  Author  to  Elucidate  the  Chief  Component 
Parts  of  the  Human  Brain. — The  lettering  upon  the  figure  will  be  explained  in  the  text. 
C.  Q.  the  corpora  quadrigemina.  The  lines  within  the  white  substance  of  the  cerebrum  or 
in  the  "crus"  are  not  intended  to  convey  any  impression  to  the  reader  of  the  actual  arrange- 
ment of  the  fibres;  nor  are  the  colors  employed  selected  with  special  reference  to  the  elucida- 
tion of  the  functions  of  the  component  parts  of  the  organ  thus  diagrammatically  shown. 

Before  we  go  farther,  let  us  examine  in  a  cursory  way  the  anatomi- 
cal elements  of  which  the  brain  is  composed.  These  are  practically  the 
same  in  all  animals  of  the  higher  grades.  We  can  then  review  the  group- 
ing of  these  elements,  and  study  some  of  the  structural  details  of  that 
organ  in  man.  Many  of  these  have  baffled  all  attempts  at  investigation 
until  of  late. 

*The  distinction  between  ''  ijixtdnctive"  or  automatic  acts  (which  are  governed  by 
the  spinal  and  cerebral  ganglia)  and  "  conscious  volitional  acts  "  (which  are  always  of  cor- 
tical origin)  is  not  properly  recognized  by  some  experimental  physiologists.  Dr.  M.  Allen 
Starr  has  very  happily  shown  in  a  late  article  on  speech  {Princeton  Eei'iev)  that  this  dis- 
tinction helps  materially  to  reconcile  the  antagonistic  views  now  held  by  the  opponents 
and  supporters  of  cerebral  localization. 


6  LECTURES    ON   NERVOUS   DISEASES. 

We  may  sturt  with  the  statement  that  the  brain  consists  of  two  dis- 
tinct anatomical  elements, — hrain  cells  and  nerve  fibres. 

The  number  of  brain  cells  in  the  cerebrum  alone  may  be  estimated 
at  many  thousands.  Each  cell,  by  means  of  its  nerve  fibres  and  the  pro- 
cesses that  spring  from  it,  may  be  considered  as  a  central  station  of  an 
electric  system.  It  can  receive  messages  from  parts  more  or  less  distant. 
It  can  dispatcli  messages  in  response  to  those  received.  Finally,  it  can 
store  up  such  information  as  may  be  carried  to  it  from  time  to  time  for 
future  use,  affording  us,  at  the  same  time,  memories  of  past  events.  It 
will  simplify  description  if  we  consider  each  of  the  anatomical  elements 
of  the  brain  separately. 

THE    BRAIN     CELLS, 

These  are  placed  chiefly  upon  the  exterior  of  the  organ,  which  is 
thrown  into  alternating  ridges  and  depressions,  somewhat  like  a  fan  when 
half  closed.  The  ridges  are  called  the  "  convolutions,"  and  the  de])res- 
sions  are  termed  "  sulci;"  or  "  fissures,"  in  case  they  are  deeper  than  the 
rest.  The  gray  matter  upon  the  exterior  of  the  brain  is  called  the 
"  cortex.''' 

The  cerebral  cortex  is  alone  associated  with  consciousness  and  voli- 
tion. Like  gray  matter  found  in  other  regions  of  the  organ,  the  cortex 
consists  of  brain  cells  and  a  cement  (formed  of  connective-tissue  elements) 
that  binds  them  together.     This  is  called  the  '■'■  neuroglia. ^^ 

Masses  of  brain  cells  are  found  imbedded  withiti  the  substance  of 
the  organ;  but  their  functions  are  less  well  determined  than  those  of  the 
cortical  gray  matter.  The  corpus  striatum*  and  the  optic  thalamus  are 
certainly  the  largest  and  perhaps  the  most  important  of  these  ganglionic 
masses. 

If  we  study  the  appearance  of  the  biain  cells  under  the  micro- 
scope, we  find  that  different  convolutions  of  the  brain  are  peopled  with 
cells  that  have  individual  characteristics  of  form  and  construction; 
hence  we  are  justified  (from  an  anatomical  stand-point  alone)  in  attrib- 
uting different  functions  to  individual  areas  of  the  cortex.  This  view  is 
sustained,  furthermore,  b}^  physiological  and  pathological  investigation. 
We  may  consider  each  cell  within  the  brain  as  possessing  an  individ- 
uality. Each. is  intrusted  with  and  controls  some  particular  function. 
Each  is  in  telegraphic  communication  with  other  cells,  and  participates 
constantly  in  the  growth  and  development  of  some  special  region  of  the 
body,  acting  in  harmony  with  its  fellows.  Luys,  who  has  carefully  in- 
vestigated the  structure  of  these  minute  bodies,  says  of  them  :  "  Imagina- 

*I  apply  the  term  "corpus  striatum"  througliout  this  work  to  its  two  halves  (the 
caudate  and  lenticular  nuclei,  Fig.  6)  collectively.  Many  of  the  German  authorities  em- 
ploy it  as  synonymous  with  the  caudate  nucleus  alone. 


THE   BRAIN    CELLS.  7 

tion  is  confounded  when  we  penetrnte  into  this  world  of  the  infinitely 
little,  where  we  find  the  same  infinite  divisions  of  matter  that  so  vividly 
impress  ns  in  the  study  of  the  sidereal  world ;  and  when  we  thus  behold 
the  m3'sterious  details  of  the  organization  of  an  anatomical  element,  which 
only  reveal  themselves  when  magnified  seven  hundred  to  eight  hundred 
diameters,  and  think  that  this  same  anatomical  element  repeats  itself  a 
thousandfold  throughout  the  whole  thickness  of  the  cerebral  cortex,  we 
cannot  help  being  seized  with  admiration,  especially  when  we  think  that 


Fig  2. — Cortical  Cell  of  the  Deeper  Zones  at  about  Eight  Hundred  Diameters.  (After 
Luys.)  A  section  of  the  cell  is  made  through  its  greater  axis,  its  interior  texture  being  thus 
laid  bare.  A,  represents  the  superior  prolongation  radiating  from  the  mass  of  the  nucleus 
itself.  B,  lateral  and  posterior  prolongations.  C,  spongy  areolar  substance,  into  which  the 
structure  of  the  cell  itself  is  resolved.  I),  the  nucleus  itself,  which  seems  only  to  be  a  thick- 
ening of  this  areolar  stroma;  it  sometimes  has  a  radiated  arrangement.  E,  the  bright 
nucleolus,  which  is  itself  decomposable  into  secondary  filaments.  The  colors  are  only  em- 
ployed to  aid  in  recognizing  the  various  parts  of  the  cell. 


each  of  these  little  organs  has  its  autonomy,  its  individuality,  its  minute 
organic  sensibility,  that  it  is  united  with  its  fellows,  that  it  participates 
in  the  common  life,  and  that,  above  all,  it  is  a  silent  and  indefatigable 
worker,  disci'eetly  elaborating  those  nervous  forces  of  the  psychic 
activity  which  are  incessantl}'  expended  in  all  directions  and  in  the  most 


»  LECTURES    ON    NERVOUS    DISEASES. 

varied  manners,  according  to  the  different  calls  made  upon  it,  and  set  it 
vibrating.'" 

In  the  cortex  of  the  brain  we  find  tlie  brain  cells  arranged  in  super- 
imposed strata.  The  number  of  these  strata  varies  in  different  areas  of 
the  brain  surface. 

Each  stratum  is  composed  of  cells  that  have  identical  shapes,  and 
whose  structure  is  apparently  the  same.  Delicate,  hair-like  processes 
are  given  off  from  the  body  of  each  cell,  many  of  which  subdivide  like 
the  branches  of  a  tree,  and  become  closely  intermingled  with  those  given 
oft'  from  neighboring  cells.  Some  of  these  processes  unquestionably 
serve  to  connect  the  cells  that  compose  the  various  strata  of  the  cortex ; 
others  serve  as  a  means  of  attachment  of  nerve  fibres  to  the  cells.  By 
means  of  these  processes,  molecular  movements  generated  within  any 
individual  cell  can  probably  be  transmitted  to  other  cells  in  the  same 
stratum  of  the  cortex,  or  to  those  composing  other  strata.  Tiius  the 
different  layers  of  cells  can  probably  act  independenlly,  or  in  conjunction 
with  others. 

We  may  generalize  respecting  the  purposes  for  which  these  minute 
bodies  have  been,  constructed,  as  follows  : — 

1.  Some  cells  are  unquestionably  capable  of  generating  nerve  force ; 
just  as  the  electric  batter}-,  for  example,  generates  electricitj-  for  the 
purpose  of  telegraphy. 

2.  Some  are  designed  to  promote  muscular  contraction,  and  thus 
to  cause  voluntary  movements.  They  are  enabled  to  do  this  by  the 
nerve  fibres.  These  conduct  the  current  from  the  cells  to  definite 
muscles  of  the  body.  vVhen,  therefore,  from  any  cause  the  generating 
power  of  motor  cells,  or  the  conducting  power  of  motor  fibres  is  inter- 
fered with,  we  have  a  sj-mptom  produced  known  as  "  motor  paral3sls." 

Tumors,  or  inflammatory  deposits  sometimes  press  upon  the  motor 
cells  to  such  an  extent  as  to  impair  their  function ;  inflammatory  con- 
ditions may  affect  them  directly,  and  cause  their  disintegration  ;  blood 
may  escape  into  the  brain  substance  and  plough  up  the  delicate  fibres 
that  convey  the  impulses  to  the  muscles  (the  condition  known  as  "  apo- 
plexy ") ;  and  many  other  pathological  conditions  may  derange  or  de- 
stroy this  elaborate  system  of  wires'  and  batteries.  Let  me  impress  upon 
the  reader  that  paralysis  of  motion  is  not  a  disease,  as  most  people  sup- 
pose.    It  is  but  one  of  the  manifestations  of  disease. 

3.  Some  cells  of  the  cerebral  cortex  serve  as  receptacles  for  nerv- 
ous impressions*  Let  us  cite  some  examples.  At  birth  the  brain  may 
be  likened  to  the  sensitized  photographic  plate  before  it  has  been  ex- 

*  Disturbances  of  the  memory  may  often  prove  a  valuable  aid  in  localizing  the  seat 
of  a  cerebral  lesion.  This  fact  has  only  been  utilized  of  late ;  as  new  facts  in  cerebral  phy- 
Biology  have  been  brought  to  light. 


THE   BRAIN    CELLS.  9 

posed  to  the  aetioii  ol"  the  lenses  of  the  camera.  Nothing  has  yet 
been  recorded  ui)on  it.  It  may  subsequently  be  beautified  or  distigured 
by  the  impressions  that  are  to  be  made  ujion  it  from  without.  At  first 
the  child  stares  stupidly  about,  unable  to  appreciate  or  properly  inter})ret 
the  pictures  that  are  constantly  being  formed  upon  the  retina  b}^  light. 
Loud  noises  frighten  it,  and  softer  sounds  fail  to  attract  its  attention. 
It  has  not  yet  learned  to  determine  the  direction  from  which  a  sound 
comes.  The  appreciation  of  distance  has  not  yet  been  acquired.  The 
tiny  hands  are  stretched  out  alike  at  remote  and  near  objects. 

Now  mark  the  change  that  occurs  when  sufticient  time  has  elapsed 
to  allow  the  brain  cells  to  accumulate  memories  of  past  events  in  num- 
bers sufficient  to  admit  of  comparison  with  each  otlier,  and  to  form  the 
basis  of  judgment.*  The  child  soon  begins  to  recognize  familiar  faces. 
It  learns  to  discriminate  between  the  voice  and  touch  of  the  mother 
or  nurse  and  that  of  a  stranger.  When  onl3'  a  few  weeks  old  it  begins 
to  estimate  distance,  and  to  make  voluntary  efforts  to  grasp  sui*rounding 
objects.  Graduall}'  its  brain  learns  the  meaning  of  articulate  sounds,  and 
by  associating  such  sounds  with  definite  objects  it  acquires  a  knowledge 
of  language.  The  power  of  speech  is  developed  later  than  the  knowl- 
edge of  language,  because  the  complicated  movements  of  the  tongue, 
lips,  and  palate  are  difficult  to  perform  properly,  and  also  because  articu- 
lation must  of  necessity'  be  based  upon  a  memory  of  the  various  sounds 
employed.  Thus  for  many  months  the  brain  of  a  child  is  simply  re- 
ceiving and  storing  up  in  these  wonderful  rece])tacles,  the  brain  cells, 
the  impressions  of  the  external  world,  that  reach  it  chiefly  by  means  of 
the  organs  of  sight,  smell,  hearing,  taste,  and  touch. 

These  facts  become  even  more  mysterious  than  the}^  might  at  first 
appear  to  the  reader  when  we  reflect  that  the  eye,  for  example,  telegraphs 
the  outline,  coloring,  and  other  details  of  every  picture  (focused  by  its 
lenses  upon  the  retina)  to  the  cells  in  the  cortex  of  the  occipital  lobes  of 
the  cerebral  hemispheres ;  and  that  these  cells  retain  these  impressions 
in  such  a  manner  that  they  can  be  recalled  by  a  voluntary  effort  again 
and  again  as  memories  of  what  we  have  seen.  The  eye  can  thus  go  on 
taking  photogi-aphs  of  external  objects  forever  without  fear  of  losing 
what  it  so  elaborateh'  duplicates.  We  have  positive  evidence  to  prove 
the  accuracy  of  these  statements.  If  the  occipital  lobes  of  both  hemis- 
pheres be  destroyed  in  animals,  the  sense  of  sight  is  lost  immediately, 
in  spite  of  the  fact  that  the  eyes  have  not  been  injured  by  the  operation. 
I   have   had    under  mj'  care  several    patients  who   have  been   rendered 

*  Clinical  observation,  as  well  as  pathological  statistics  go  to  show  that  in  right- 
handed  subjects  the  left  cerebral  hemisphere  is  more  intimately  connected  with  the  storage 
of  memories  than  the  right  hemisphere.  This  is  well  illustrated  in  the  reported  cases  of 
ataxic  aphasia,  paraphasia,  word-blindness,  and  word-deafness. 


10 


LECTURES    ON   NERVOUS   DISEASES. 


totally  blind  in  a  lateral  half  ol'  each  eye  by  brain-disease ;  the  other 
half  retaining  its  normal  power  of  vision.  It  is  equally  well  proven  that 
the  memories  of  our  conscious  perceptions  of  odors,  sounds,  taste,  and 
touch,  are  stored  within  the  cells  of  different  areas  of  the  cerebral  cortex, 
whose  limits  are  already  determined  with  approximate  accuracy.  These 
memories,  as  we  all  know,  can  be  recalled  at  will  with  unimpaired  vivid- 
ness, just  as  picture  after  picture  can  be  struck  off  the  same  negative 
when  once  made  indelible  upon  a  glass  plate. 


ff^9^!^ 


LOBE 


"^t-^^^oy^^^ 


Fig.  3. — Side  View  op  the  Brain  op  Man  Showing  the  Areas  op  the  Cerbbrai,  Con- 
volutions. (Modified  slightly  from  Kerrier. )  K,  Fissure  of  Rolando.  S,  Fissure  of  Syl- 
vius, divided  into  its  two  branches.  1  (on  the  postero-parietal  [superior  parietal]  lobule). 
Advance  of  the  opposite  hind-limb  as  in  walking.  2,  .3,  4  (around  the  upper  extremity  of  the 
fissure  of  Rolando).  Comple.v  movements  of  the  opposite  leg  and  arm  and  of  the  trunk,  as  in 
swimming;  a,  b,  c,  d  (on  the  ascending  parietal  [posterior  central]  convolution),  individual 
and  combined  movements  of  the  fingers  and  wrist  of  the  opposite  hand ;  prehensile  move- 
ments. 5  (at  the  posterior  extremity  or  the  superior  frontal  convolution).  Extension  for- 
ward of  the  opposite  arm  and  hand.  6  (on  the  upper  part  of  the  antero-parietal  or  ascend- 
ing frontal  [anterior  central]  convolution).  Supination  and  flexion  of  the  opposite  forearm. 
7  (on  the  median  portion  of  the  same  convolution)  Retraction  and  elevation  of  the  oppo- 
site angle  of  the  mouth  by  means  of  the  zygomatic  muscles.  8  (lower  down  on  the  same  con- 
volution). Elevation  of  the  ala  nasi  and  upper  lip  with  depression  of  the  lower  lip  on  the 
opposite  side.  9,  10  (at  the  inferior  extremity  of  the  same  convolution,  Broca's  convolution). 
Opening  of  the  mouth  with  9,  protrusion;  and  10,  retraction  of  the  tongue, — region  of  aphasia, 
bi-lateral  action.  11  (between  10  and  the  inferior  extremity  of  the  ascending  parietal  convo- 
lution). Retraction  of  the  opposite  angle  of  the  mouth,  the  head  turned  slightly  to  one  side. 
12  (on  the  posterior  portions  of  the  superior  and  middle  frontal  convolutions).  The  eyes 
open  widely,  the  pupils  dilate,  and  the  head  and  eyes  turned  toward  the  opposite  side.  13, 13 
(centres  of  vision  in  the  occipital  lobes).  14  (of  the  infra-marginal,  or  superior  [first]  tem- 
poro-sphenoidal  convolution).  Pricking  of  the  opposite  ear,  the  head  and  eyes  turned  to  the 
opposite  side,  and  the  pupils  dilate  largely  (centre  of  hearing).  Ferrier,  moreover,  places 
the  centres  of  taste  and  smell  (l.'j)  at  the  extremity  of  the  temporo-sphenoidal  lobe,  and  that 
of  touch  in  the  gyrus  uncinatus  and  hippocampus  major. 

Professor  Ferrier,  of  London,  has  mapped  out,  by  means  of  a  series 
of  experiments  upon  the  monke}^  tribe  (the  nearest  approach  to  the  type 
of  man),  a  chart  of  the  brain  which  shows  the  situation  of  certain  groups 


THE    CEliEBKAL    COETEX.  11 

of  cells  or  "centres"  in  the  cortex  that  preside  over  particular  functions. 
The  cut  introduced  (Fig-.  3),  and  its  descriptive  text,  will  make  some  of 
the  conclusions  of  this  author  intelligible  to  the  reader.* 

Most  of  the  conclusions  of  tliis  investigator  (excepting  those  relating 
to  the  visual  centres,  in  which  I  tliink  he  is  in  error)  have  been  partially 
verified  upon  man.  It  may  interest  the  reader  to  know  how  these  con- 
clusions have  been  verified,  since  vivisection  upon  the  human  race  is,  of 
course,  impossible. 

In  the  first  place,  a  careful  study  has  been  made  of  cases  where 
Nature  has  performed  the  experiment  of  destroying  or  imperfectl}''  de- 
veloping portions  of  the  brain,  and  where  an  opportunity  of  examining 
that  organ  after  death  has  been  afforded. f  The  clinical  records  of  such 
cases  have  been  collected  from  all  reliable  sources,  and  critically  ana- 
lyzed by  competent  medical  men  (Charcot,  Ferrier,  Nothnagel,  Wernicke, 
Broadbent,  Luys,  p]xner,  Spitzka,  Starr,  Seguin,  and  many  others). 

Again,  a  large  number  of  subjects  who  have  suftered  amputation  of 
limbs,  and  who  have  survived  the  operation  for  some  3'ears,  or  who  have 
manifested  arrested  development  of  limb,  have  been  made  to  bear  indirect 
testimony  to  the  accuracy  of  the  facts  gained  by  vivisection  and  patho- 
logical research.  When  any  part  of  the  body  is  deprived  of  exercise, 
it  will  waste  gradually  from  disuse.  On  this  basis  of  reasoning.  Bourdon 
and  others  have  sought  to  determine  the  centres  of  motion  of  the  limbs, 
by  examining  the  cortex  of  the  cerebral  hemispheres  of  such  subjects 
after  death,  with  a  view  of  determining  the  existence  and  exact  seat  of 
atrophy  of  definite  groups  of  brain  cells. 

A  third  line  of  investigation,  which  has  yielded  brilliant  results, 
consists  in  tracing  the  origin,  course,  and  ultimate  distribution  of  sepa- 
rate bundles  of  nerve  fibres  within  the  brain  and  spinal  cord  (Meynert, 
Flechsig,  Gudden,  Wernicke,  Spitzka,  Aeby,  Roller,  Starr,  and  many 
others).  Some  important  discoveries  have  been  made  of  late,  which 
enable  us  to  do  this  with  accuracy, — a  feat  that  was  impossible  by  the 
older  methods  employed.  A  knowledge  of  the  peripheral  connections 
of  certain  groups  of  brain  cells  has  shed  much  light  upon  their  probable 
functions. 

Finally,  much  has  been  learned  by  a  microscopical  study  of  the  dif- 
ferent layers  of  the  cortex  and  the  nerve-nuclei  with  reference  to  the 

*  The  view  upheld  by  Ferrier  and  Munk  that  the  cortical  areas  have  distinct  lines  of 
demarcation  has  been  opposed  bj'  Luciani  and  Exner,  who  believe  that  the  edges  of  these 
areas  merge  gradually  into  each  other,  and  manifest  less  pi'ominently  than  do  their  cen- 
tral portions  the  individual  peculiarities  of  each. 

t  The  study  of  microcephalic  specimens,  which  bears  somewhat  upon  this  field,  bids 
fair  to  become  a  very  important  line  of  investigation  respecting  the  relations  of  certain 
parts  of  the  brain  to  definitely  recognized  bundles  of  fibres  within  the  crus,  pons,  medulla, 
and  spinal  cord.     It  is  as  yet  in  its  infancy. 


12 


LECTURES   ON    NERVOUS   DISEASES. 


character  of  cells  tbtit  compose  tlieni.  It  has  been  proven  that  the  form 
and  arrangement  of  the  brain  cells  atford  some  clue  to  the  special  func- 
tions over  which  each  preside  (Luvs,  Arndt,  Betz,  Stephany.  Spitzka, 
and  others).     Comparative  anatomy  has  aided  in  this  line  of  research. 

Now,  when  we  find  that  all  of  these  methods  lead  us  to  an  identical 
conclusion  concerning  any  point  in  cerebral  ph3'siolog3\  that  conclusion 
becomes  a  fact  beyond  the  possibility  of  dispute.  Unfortunately  for 
science,  much  still  remains  to  be  determined  regarding  this  mysterious 
mechanism ;  but,  on  the  other  hand,  much  has  been  positively  proven. 
Perhaps  the  day  may  never  come  when  the  human  mind  can  fathom  all 
of  its  mysteries. 


^^^^^Z 


Fig.  4. — A  Diagrammatic  Figure,  Showing  the  Cekebrai.  Convolutions.  (Modified 
from  Dalton. )  S,  Fissure  of  Sylvius,  with  its  two  branches,  a,  and  6,  b,  b.  R,  Fissure 
of  Rolando.  P,  Parietooccipital  fissure.  1,  1,  1,'rhe  first,  or  superior  frontal  convolution. 
2,  2,  2,  2,  The  second,  or  middle  frontal  convolution.  3,  .3,  H,  The  third  frontal  convolution, 
curving  around  the  ascending  limb  of  the  fissure  of  Sylvius  (centre  of  speech  movements). 
4,4,  4,  Ascending  frontal  (anterior  central)  convolution.  .5,  .5,  .5,  .Ascending  parietal  (posterior 
central)  convolution.  6,  6,  6,  Supra- Sylvian  convolution,  which  is  continuous  with  7,  7,  7, 
the  first  or  superior  tempor.al  convolution.  8,  S,  S,  The  angular  convolution  (or  gyrus),  which 
becomes  continuous  with  ft,  9,  9,  the  middle  temporal  convolution,  lit.  The  third,  or  inferior 
temporal  convolution.  11,  11,  The  superior  parietal  convolution.  12,  12,  12,  The  superior, 
middle,  and  inferior  occipital  convolutions,  called  also  the  first,  second,  and  third  (the  centres 
of  vision).  It  is  to  be  remembered  that  the  term  "gyrus"  is  synonymous  with  "convolu- 
tion," and  that  both  terms  are  often  interchanged. 

Before  we  pass  to  the  consideration  of  the  second  anatomical  element 
of  nervous  tissues — the  nerve  fibres — let  me  call  the  attention  of  the  reader 
to  the  general  form  of  the  brain,  and  to  a  classification  of  the  convolutions 


THE   CEKEBKAL   COETEX.  13 

that  is  now  generally  ado[)ted.  This  '.vill  enable  him  to  gain  a  clear  in- 
sight into  the  functions  of  difterent  areas  of  the  cerebral  cortex.  Fig.  4 
should  be  compared  with  Fig  5,  as  each  will  help  to  interpret  the  other. 

The  lobes  of  the  cerebrum  are  named  respectively'  the  frontal,  parie- 
tal, occipital,  and  temporal,  from  the  bones  with  which  they  lie  in  con- 
tact. They  are  demarcated  from  each  other  by  lissures  or  clefts  that  are 
clearly  delined  and  more  delinitely  placed  than  the  sulci. 

The  fissures  of  Rolando  and  of  Sylvius  and  the  parieto-occipital 
fissure  are  of  special  importance.     (Fig.  4.) 

The  diagram  shows  that  the  frontal  and  parietal  lobes  have  four 
convolutions  each,  and  the  occipital  and  temporal  lobes  three  each. 

It  must  be  remenil)ered  that  the  cerebrum  has  two  hemispheres — a 
right  and  a  left — only  one  of  which  is  seen  in  profile.  The  right  hemis- 
phere is  associated  chiefly  with  the  left  lateral  half  of  the  body,  and  the 
left  hemisphere  with  the  right  lateral  half.  Disease  of  one  hemisphere 
of  the  brain  may  produce,  therefore,  a  disturbance  of  some  or  all  of  the 
functions  of  the  opposite  side  of  the  body  below  the  head.  There  are  ex- 
ceptions to  this  rule,  but  it  is  a  safe  one  to  follow  in  the  majority  of  cases. 

Another  diagram  (Fig.  5)  will  be  introduced  later  to  show  certain 
areas  of  the  surface  of  the  hrain  that  are  believed,  in  the  light  of  our 
present  knowledge,  to  preside  over  special  functions,  as,  for  example, 
those  of  speech,  muscular  movements  of  the  extremities,  sight,  hearing, 
smell,  and  touch. 

In  summary-,  we  are  justified  in  drawing  the  following  conclusions 
respecting  the  cells  of  the  cerebral  cortex  from  the  results  obtained  by 
experimentation,  clinical  experience,  and  pathological  data: — 

1.  The  surface  of  the  hrain  is  the  seat  of  all  conscious  mental 
action.  It  is  the  receptacle  of  all  impressions  made  upon  the  organs  of 
smell,  sight,  taste,  hearing,  and  the  tactile  organs  of  the  skin.  Here, 
and  onl}'  here,  do  such  impressions  become  transformed  into  a  conscious 
appreciation  of  external  objects. 

2.  The  mental  powers  are  the  result  of  difterent  combinations  of 
memories  of  past  events  stored  in  the  cells  connected  with  the  special 
senses,  and  the  activity  of  other  groups  of  cells  that  are  probal)ly  situ- 
ated in  the  frontal  lobes.  Although  the  integrity  of  the  entire  organ 
is  necessary  to  the  unimpeded  action  of  the  higher  mental  faculties 
(such  as  judgment,  will,  self-control,  reason,  etc.),  the  cells  of  that  por- 
tion of  the  frontal  lobes  that  lies  in  front  of  the  motor  centres  are  per- 
haps more  closely  associated  with  these  faculties  than  those  of  any  other 
area.     (Fig.  5.) 

3.  The  central  convolutions*  of  the  brain  (a  i)art  of  the  frontal  and 

*  Chiefly  the  preceiitral  gyrus.  The  post^ecntral  gyrus  appears  to  be  associated  with 
both  motion  and  sensation  to  a  greater  extent  titan  the  precentral. 


14 


LECTUKES   ON   NERVOUS   DISEASES. 


parietal  lobes  of  each  hemisphere)  preside  over  motion  and  the  meroorv 
of  all  motor  acts  of  the  limbs  and  body.  The  upper  part  governs  the 
legs  chiefly,  the  middle  part  controls  the  upper  extremity,  while  the 
lower  part  presides  over  the  complex  movements  of  the  tongue  and  lips 
necessar}^  to  speech.  The  memories  of  muscular  acts  are  probably  stored 
within  the  cells  of  the  motor  area.  It  is  also  probable  that  some  forms 
of  sensation  are  appreciated  by  the  smaller  cells  of  this  area  (Moeli, 
Tripier,  and  others). 

MOTOR-  ^^^ 


SVLVIAN  \    I 
F/3SUH£^    ^ 


Fig.  5.- 


-A  Diagram  Designed  by  the  Author  to  Illustrate  the  Probable  Functions 
OF  Different  Areas  of  the  Cerebral  Cortex. 


The  limits  of  these  areas  must  not  l)e  interpreted  too  literally  by 
the  reader  as  a  basis  for  diagnosis.  Each  area  probably  merges  almost 
imperceptibly  into  those  which  lie  adjacent  to  it.  The  central  portion 
of  each  are  more  clearly  related  to  special  functions  than  the  peripheral 
portions. 

The  so-called  "motor  area"  is  probably  connected  not  onl}^  with 
voluntary  muscular  contractions,  but  also  with  the  conscious  apprecia- 
tion of  all  sensory  impressions  connected  with  the  muscles.  It  might, 
therefore,  be  more  properly  designated  as  the  ^'muscular  area.''^ 


THE   (CEREBRAL    CORTEX.  15 

4.  The  occipital  lobes*  preside  over  the  sense  of  sight  and  the  memo- 
ries of  sight-pictures  (Munk,  Wernicke,  and  others).  The  recognition 
of  familiar  objects  by  the  eyes  depends  on  the  aetivit3^  of  the  cells  in  the 
cortex  of  these  lobes.  Hallucinations  of  vision  point  strongly  toward  a 
disturbance  of  the  function  of  these  cells.  An  inabilit}'  to  recognize 
familiar  objects,  such  as  faces,  letters,  words,  etc.,  is  one  of  the  promi- 
nent symptoms  of  disease  of  the  occipital  region,  provided  the  eyes  are 
capable  of  performing  their  normal  functions.  Colored  perceptions  of 
objects  and  other  ocular  spectra  often  accompany  irritation  of  these 
lobes.  If  the  whole  of  the  occipital  lobe  be  not  destroyed,  the  unim- 
paired part  may  slowly  accumulate  new  sight  memories,  and  the  sense 
of  vision  may  thus  be  slowl}'  regained.  This  has  been  proven  upon  the 
dog  by  Munk. 

5.  That  part  of  the  parietal  lobes  which  is  not  occupied  by  special 
centres  of  motion  is  probably  associated  with  the  conscious  perceptions 
of  various  tactile  impressions  and  the  associated  memories  of  touch, 
temperature,  degrees  of  pressure,  and  pain. 

6.  The  temporal  lobes  are  the  probable  seat  of  our  conscious  appre- 
ciation of  sounds,  odors,  and  taste  (Ferrier,  Kussmaul,  Gudden,  and 
others).  When  these  lobes  are  diseased,  the  memory  of  spoken  words 
ma}'  be  obliterated,  and  hallucinations  of  hearing  or  deafness  maj^  be  de- 
veloped. I  once  encountered  an  interesting  ease  where  hallucinations  of 
smell  (imaginary  odors)  existed  in  consequence  of  disease  involving  the 
apex  of  this  lobe.  Persons  who  have  been  suddenly  deprived  of  their 
ability  U^  appreciate  a  question  when  spoken.  Init  who  would  reply 
promptly  to  the  same  question  if  written  before  their  eyes,  have  been 
rei)orted.  In  such  the  memories  of  sound  liave  been  obliterated  by  dis- 
ease of  the  temporal  lobe,  but  the  memories  of  the  form  and  meaning 
of  letters  have  remained  intact,  because  the  occipital  lobes  were  not 
involved.  These  patients  can  sometimes  be  made  to  repeat  mechanically 
word  upon  word,  in  a  parrot-like  way,  but  the  memory  of  their  meaning 
has  gone  forever. 

7.  The  power  of  speech  (when  regarded  as  a  merely  mechanical  per- 
formance) seems  to  be  governed  by  the  inferior  frontal  convolution  and 
the  area  adjacent  to   it  around   the  lower   part  of  the   fissure  of  Sylvius. 

*  Ferrier  originally  iJlaeed  the  visual  centres  iu  the  amjular  convoliUion  of  the  parietal 
lobe  (Fig.  4).  I  am  led  to  believe  that  this  is  an  error.  This  seems  to  be  proven  by  an 
analysis  of  cases  collected  and  published  by  Starr  and  Seguin.  Wernicke  has  also  lately 
shown  that  the  visual  fibres  pass  beneath  the  cortex  of  the  angular  g.vrus  in  order  to  reach 
the  occipital  cortex.  This  discovery  helps  to  explain  the  effects  of  destruction  of  the 
angular  gyrus  upon  sight,  as  observed  by  Ferrier,  Daltou,  and  others.  Sight  was  de- 
stroyed by  these  observers,  probably,  by  damage  done  to  tracts  of  fibres  lying  beneath 
the  cortex,  rather  than  by  a  destruction  of  the  cortical  cells  alone. 


16  LECTURES   ON    NERVOUS   DISEASES. 

(Fig.  24  )*  But  it  must  l)e  remembered  that  our  remarks  are  usually 
called  forth  by  some  form  of  excitation,  such  as  a  spoken  question,  an 
impression  upon  the  eye,  or  some  form  of  irritation  of  the  sensory 
nerves,  as  in  the  case  of  pain,  tickling,  etc.,  for  example.  Disease  of 
this  limited  area  of  the  brain  surface  causes  patients  to  frequently 
interpolate  wrong  words  in  conversation,  in  spite  of  the  fact  that  they 
grasp  the  meaning  of  all  that  transpires  about  them,  and  have  the 
memories  of  past  events  perfectly  at  their  command.  Such  a  subject 
could  write  a  reply  to  any  spoken  or  written  question  with  perfect 
accuracy,  although  he  might  speak  it  incorrectly.  If  he  were  asked 
to  repeat  words  selected  as  a  test  of  coordinated  movements  of  the 
tongue  and  lips,  he  would  probabl}-  fail  to  do  so  with  his  accustomed 
facility.     This  subject  will  be  discussed  in  subsequent  pages. 

8.  That  we  are  endowed  with  memories  of  muscular  morements  is 
well  illustrated  by  a  case  observed  by  Professor  Charcot,  of  a  gentleman 
who  was  rendered  incapable,  by  disease  of  his  brain,  of  recognizing  either 
printed  or  written  language,  but  who  could  grasp  the  meaning  of  both 
with  ease  by  tracing  out  the  curves  with  his  fingers.  The  habit  of 
writing  had  impressed  the  mind  with  the  symbols  of  thought,  through 
the  agency  of  the  muscles. 

9.  Some  collections  of  cells  within  the  deeper  parts  of  the  brain 
(the  corpus  striatum  and  optic  thalamus  of  each  cerebral  hemisphere) 
are  probablj'  distributing  centres  for  all  impulses  that  pass  either  to  or 
from  the  cerebral  cortex. 

They  act  as  "middle-men,"  as  it  were.  The}-  are  capable,  as  illus- 
trated in  the  case  of  the  mutilated  frog  previously  referred  to,  of  an  au- 
tomatic control  over  movements ;  but,  as  far  as  we  know,  there  is  no 
reason  to  think  that  they  are  associated  in  any  way  with  the  attribute  of 
consciousness. 

10.  The  functions  of  the  cerebellum,  the  pons  Varolii,  and  the  me- 
dulla oblongata  (see  Fig.  1)  are  too  complex  to  be  fully  discussed  here. 
Their  cells  are  called  into  action  in  a  reflex  manner,  rather  than  by  voli- 
tion. There  is  reason  to  believe  that  the  cerebellum  is  an  "  informing 
depot"  for  the  cei'ebrum  (Spitzka),  and  a  "store-house  for  nerve  force" 
(Mitchell).  The  medulla  oblongata  presides  over  acts  that  are  chiefly 
outside  of  the  domain  of  the  will ;  such  as  the  beating  of  the  heart,  the 
worm-like  movement  of  the  intestine,  the  regulation  of  the  calibre  of  the 

*  Destruction  of  the  centre  of  Broca  and  the  island  of  Reil,  seems  to  deprive  the  indi- 
vidual of  those  memories  which  are  associated  with  the  proper  coordination  of  the  apparatus 
of  speech.  Such  patients  cannot  pronounce  words  which  they  ma}-  be  able  either  to  recog- 
nize by  sight  or  to  understand  perfectly  when  spoken.  The  substitution  of  wrong  words 
in  conversation  (paraphasia)  is  more  commonly  encountered  than  true  ataxic  aphasia 
when  the  island  of  Reil  is  involved.     This  subject  will  be  more  fully  discussed  later. 


THE   NERVE   FIBRES.  17 

blood-vessels  to  the  wants  of  the  different  organs,  the  modifications  of 
blood-pressure,  and  other  functions  that  are  essentially  vital. 

THE     NERVE     FIBRES. 

We  now  come  to  the  second  anatomical  element  of  nervous  tissues. 
If  we  pull  a  brain  apart  so  as  to  expose  its  central  portions,  we  shall  be 
able  to  see  that  distinct  bundles  of  extremely  delicate  white  threads  com- 
pose each  '' crus  cerebri,"  or  the  leg  of  the  hemisphere  (Fig.  I),  and 
that  the  thousand  filaments  which  form  each  bundle  diverge  within  the 
hemisphere  and  pass  to  its  surface.  We  have  grounds  for  the  belief  that 
each  of  these  threads  becomes  united  to  a  cell. 

These  ai'e  the  nerve  fibres.  Each  of  these  threads  is  insulated  by 
a  protective  covering  so  as  to  prevent  the  diffusion  of  its  currents  to 
other  fibres.  The  white  substance  of  the  brain  is  composed  exclusively 
of  fibres. 

Of  those  that  constitute  the  central  portion  of  the  cerebrum,  one  set 
serves  to  connect  the  cells  of  different  areas  of  the  cortex  of  each  hemis- 
phere (the  '^associating  fibres^'').  These  do  not  cross  the  mesial  line  of 
the  skull.  They  allow  of  comparison  of  different  memories,  etc..  and  are 
l)robably  essential  to  the  higher  mental  faculties.  The  areas  of  sight, 
hearing,  smell,  motion,  general  sensibility,  and  taste,  of  each  cerebral 
hemisphere,  are  thus  brought  into  communication  Avith  each  other. 
These  fibres  will  be  discussed  at  a  greater  length  in  connection  with 
aphasia. 

A  second  set  serves  to  join  the  cortical  cells  of  homologous  parts 
of  the  two  hemispheres  of  the  cerebrum.  They  are  evidently  designed 
to  promote  a  simultaneous  action  of  the  two  hemispheres  upon  corre- 
sponding parts  of  the  bod}',  as  illustrated  in  rowing  a  boat  with  two 
hands,  swimming,  etc.     These  are  called  "  commissured  fibres.''^  (Fig.  6.) 

A  third  set  comprises  those  fibres  that  pass  from  each  hemisphere 
into  the  spinal  cord.  These  are  known  as  the  ^' peduncular  fibres, ^^ 
because  they  help  to  form  the  stem  of  the  brain,  or  the  crus  cerebri  (see 
Figs.  1  and  6). 

A  fourth  set  may  be  said  to  comprise  those  fibres  that  are  associated 
directly  with  the  organs  of  special  sense,  the  nose,  eye,  ear,  tongue,  and 
skin.     Some  of  these  belong  to  the  peduncular  group. 

Finally,  a  fifth  set,  known  as  the  fornix,  serves  to  connect  the  corti- 
cal cells  of  the  temporal  lobe  of  each  cerebral  hemisphere  with  a  inass  of 
cells  buried  deeply  within  the  corresponding  hemisphere,  known  as  the 
optic  thalamus.  The  function  of  these  peculiarly  arranged  fibres  is  not 
yet  determined  with  positiveness. 

We  have  already  discussed  the  role  which  the  nerve  fibres  play  in 
connection  with  the  brain  cells.     They  are  the  channels  of  transmission 


18 


LECTURES    ON   NERVOUS   DISEASES. 


of  nerve  impulses.  Some  curry  impressions  of  a  sensory  character; 
hence  their  currents  travel  from  peripheral  parts  to  the  cells  of  the  brain. 
Others  convey  motor  impulses  from  the  brain  cells  to  the  muscles. 


Fig  6 -a  Diagram  Designed  by  the  Author  to  Sho'^v  the  Genkral  Arrangement  of 
THE  Fibres  OP  THE  Cekeero-Spinal  System.  (Modified  from  L.-indois.)  The  shaded 
porUons  represent  the  collections  of  gray  matter.  (In  the  left  side  of  the  diagram,  the  ^^«- 
^TrvfiirTof  the  crus  are  traced  upward  from  the  spinal  cord  to  different  portions  of  the 
Snm; ;  on  the  r^ht  side,  the  ,.otory^^,res  are  similarly  represented  ^^i"--^'^^  =>- ^^^ 
in  desisnatine  the  sensory  and  ca,i!i>//ss!< ra/ _fil>res  :  the  t>ioio>- _^i»-es  are  lettered  in  small 
vpe  The  lorticaTlayeMs  shown  at  the  periphery  of  the  cerebral  section,  with  commis- 
si fibred  (ifconnaJting  homologous  regions  of  the  hemispheres  and  associating  hbres 
{a.s.)  connecting  different  convolutions  of  each  hemisphere,     c.n.,  Caudate  nucleus  ol  the 


THE    NERVE   FIBRES.  19 

CORPUS  striatum;  L.  N.,  ieniicu/ar  nucleus  of  the  same;  O.  T.,  optic  thalamus  of 
each  hemisphere,  united  to  its  fellow  in  the  median  line;  eg-.,  corpora  quadrigemina  ; 
c.  /.,  CLAiJSTRUM,  lying  to  the  right  of  the  letters  ;  c.  c,  corpus  callosum,  with  its  commis- 
sural fibres;  5",  fissure  of  Sylvius;  I',  lateral  ventricle,  the  fifth  ventricle  being  shown 
between  the  two  layers  of  the  septum  lucid  urn  :  C,  the  i/ia/or  tract  of  the  CRUS  cerebri  {basis 
crjtris — crusta);  7',  the  sensory  tract  of  the  CRUS  i-erebri  (tegiiientutn  cruris);  C/.the. 
cerebellar/asciculus  :  ?,the  point  of  decussation  of  the  motor  fibres  of  the  spinal  cord;  y,  the 
course  of  the  decussating  motor  fibres  of  the  spinal  cord  below  the  medulla,  showing  their 
connection  with  the  cells  of  the  anterior  horns  of  the  gray  matter,  and  their  continuation  into  the 
anterior  roots  of  the  spinal  nerves  (g) ;  rt,  fibres  which  radiate  through  the  caudate  nucleus  ;  b, 
fibres  of  the  "  internal  capsule :"  c.  fibres  which  radiate  through  the  lenticular  nucleus;  d, 
fibres  of  the  " e.rternal  capsule;"  2,  3,  4,  .5,  6,  7,  S,  9,  sensory  fibres  radiating  from  the 
tegumenium  cruris  to  the  cortex  by  means  of  various  nodal  masses  of  gray  matter;  11,  course 
of  the  sensory  fibres  of  the  spinal  cord  (shown  by  dotted  lines),  intimately  connected  with 
the  posterior  root  of  the  spinal  nerve  (12),  and  decussating  at  or  near  to  the  point  of  entrance 
into  the  spinal  cord.  This  diagram  may  be  studied  in  connection  with  Figs.  12,  1.5.  16,  36, 
and  37,  with  possible  benefit  to  the  general  reader.  In  this  diagram,  the  direct  pyramiddl 
fibres  are  not  shown  (see  Fig.  29),  nor  the  gray  matter  of  the  pons. 

Different  observers  have  been  able  to  trace  tlie  course  and  termina- 
tions of  the  separate  bundles  with  exactness  by  means  of  nietliods  lately 
discovered.  Nature,  under  certain  conditions,  makes  the  dissections 
during  life ;  and  we,  after  death,  can  study  out  the  details  of  her  work. 
In  this  way  we  have  learned  facts  that  no  human  dissection  could  have 
determined.  The  discovery  of  Tiirck  that  nerve  fibres  degenerate  (as  a 
result  of  mal-nutrition)  when  severed  from  the  nerve  cells,  enables  us  to 
investigate  the  results  that  follow  destruction  of  certain  limited  areas 
of  the  cortex  of  man  l)y  disease  or  mechanical  injury.  When  sections 
across  such  a  lirain  are  made  and  examined  under  a  glass  (proper  stain- 
ing reagents  being  employed)  the  area  of  the  degenerated  fibres  be- 
comes as  clearly  depicted  from  that  of  healthy  brain  fibres  as  would 
an  ink  spot  upon  a  table-cloth.  An  examination  of  successive  sections 
enables  us  to  ti'ace  the  course  of  the  fibres  that  were  originall3-  connected 
with  the  cells  of  the  diseased  area  to  their  peripheral  connections.  Some 
years  after  Tiirck's  original  paper,  Flechsig  opened  another  field  of  inves- 
tigation. He  showed  that  during  the  development  of  the  embryo,  certain 
bundles  of  nerve  fibres  in  the  brain  and  spinal  cord  became  completely 
formed  before  others.  B}'  means  of  sections  of  embryotic  brains,  he  and 
his  followers  have  been  able  to  confirm  many  of  the  facts  made  known  to 
us  by  Tiirck's  method.  Finally,  Gudden  has  lateh*  proven  that  extirpa- 
tion of  the  ej^e  and  some  other  organs,  as  well  as  the  divisions  of  some 
nerve-tracts,  in  the  newly-born  animal,  are  followed  by  a  proximal  degen- 
eration of  the  fibres  connected  with  the  organ  removed. 

Let  me  remark  here  that  every  nerve  impulse  sent  to  the  brain  does 
not  travel  along  a  continuous  Jibre  to  reach  the  cell  of  the  cortex  that  is 
capable  of  receiving  it;  and  the  same  holds  true  of  all  motor  impulses  dis- 
patched from  the  brain  to  the  muscles.  All  impulses  are  passed  from  cell 
to  cell  by  means  of  connecting  fibres.  In  this  wa}'  they  eventually  reach 
the  cerebral  cortex,  just  as  water-buckets  are  passed  up  a  ladder,  in  case 
of  fire,  to  use  an  illustration  borrowed  on  account  of  its  aptness.  The 
object  of  this  arrangement  is  to  allow  of  an  independent  action  of  certain 
collections  of  cells  (that  are  subservient  to  the  cortical  cells  of  the  cere- 


20  LECTURES    ON   NERVOUS   DISEASES. 

brum)  in  case  the  required  response  does  not  necessitate  volition  or  con- 
sciousness. Many  of  the  vital  processes  (such  as  the  beating  of  the  heart ) 
are  governed  by  what  is  known  as  ''retlex  action."  We  cannot  check 
tliem  by  the  will,  and,  as  a  rule,  we  are  unconscious  that  they  are  con- 
stantly going  on. 

THE   GANGLIA   AT   THE   BASE   OF   THE   CEREBRUM. 

Buried  within  the  substance  of  each  cerebral  hemisphere,  isolated 
gray  masses  (composed  of  nerve-cells)  exist.  They  may  be  revealed  by 
vertical  or  horizontal  cross-sections  of  the  hemispheres. 

Among  these  may  be  prominently  mentioned  :  (1)  the  caudate  and 
lenticular  nuclei  ot  the  corpus  striatum  (so  named  from  the  striped  appear- 
ance which  they  present)  ;  (2)  the  optic  thalamus  (a  term  which  sianifies 
the  "  bed"  of  the  optic  fibres);  (3)  the  geniculate  bodies,  connected  with 
the  optic  tracts  (Fig.  21);  (4)  the  amygdalse,  each  being  formed  by  the 
tail-like  prolongation  of  the  caudate  nucleus  of  the  corresponding  hemi- 
sphere (Fig.  9)  ;  and  (5)  the  basal  ganglia  of  Meynert. 

The  limits  of  this  chapter  will  preclude  more  than  a  hasty  and  very 
imperfect  summary  of  the  functions  of  the  corpora  striata  and  the  optic 
thalami. 

In  the  Journal  of  Nervous  and  Mental  Diseases,  I  published  some 
years  ago  two  lectures  delivered  by  me  upon  these  ganglia.  In  some 
respects,  I  have  changed  m}'  views  relating  to  a  few  disputed  points  con- 
cerning the  structure  and  probable  functions  of  these  bodies  since  these 
lectures  were  published.  I  shall  quote,  however,  some  paragraphs  from 
these  articles  from  time  to  time,  with  modifications  in  the  phraseology. 

THE   CORPUS   STRIATUM. 

Within  each  cerebral  hemisphere,  two  nodal  masses  of  cells  are  im- 
bedded, known  as  the  corpus  striatum  and  the  optic  thalamus  (Fig.  1). 
Because  these  bodies  lie  near  to  the  base  of  the  cerebrum,  the}-  are  col- 
lectivety  called  the  "  basal  ganglia  "  of  the  hemispheres. 

Each  corpus  striatum  is  divided  (by  the  fibres  which  constitute 
the  so-called  "internal  capsule"  of  each  hemisphere)  into  two  distinct 
portions;  one  of  which  projects  into  the  lateral  ventricle,  while  the  other 
does  not.  These  are  known  as  the  intra-venti-icnlor  portion,  or  the 
"  caudate  nucleus,'^  and  the  extra-ventricular  portion,  or  the  '•  lenticular 
nucleus.''''     Fig.  6  will  make  this  apparent  to  the  reader. 

The  two  nuclei  of  the  corjnis  striatum  become  joined  both  anteriorly 
and  posteriorly;  hence  the  separation  of  these  masses  is  onl}'  partial. 
Horizontal  and  vertical  cross-sections  of  the  cerebrum  show  these  nuclei 
as  distinct  from  each  other,  as  a  rule. 

Space  will  not  allow  of  an  anatomical  description  of  these  bodies. 


M 


THE   CORPUS    STRIATUM. 


21 


I  quote,  therefore,  a  few  paragraphs  from  two  monographs  of  mine,  re- 
lating to  these  nuclei : — * 

"  The  clinical  results  of  lesions  of  either  nucleus  are  attributed  by 


Afferent  fibres  of 
corpus  striatum 
"corticostriate 
group." 


Stria  cornea    I 


Efferent  fibres 
of  corpus  striatum 


Cerebellar  fibres  to 
corpus  striatum 
( according  to 
Luys). 


B 

Fig.  7. — A  Diagram  Designed  by  the  Author  to  show  the  Afferent  and  Efferent 
Fibres  of  the  Corpus  Striatum.  C.N,  "caudate  nucleus,"  or  ventricular  portion  of 
corpus  striatum;  L,  N,  "lenticular  nucleus,"  or  extra-ventricular  portion  of  corpus  stria- 
tum ;  A — B ,  median  line,  separating  cerebral  hemispheres  ;  P — F,  psycho-motor  regions  of 
the  cortex ;  a,  peduncular  fibres  connected  with  L,  N;  b,  fibres  of  the  so-called  "  internal 
capsule;"  6-,  fibres  connected  with  C.  N;   O,  olfactory  fibres.      (Luys.) 

most  authors  to  pressure  effects  upon  the  motor  fibres  of  the  internal 
capsule.  In  no  instance,  to  my  knowledge,  has  the  destruction  of  these 
nuclei  produced  psychic  manifestations. 

*  Journal  of  Nervous  and  Meiital  Biseases,  1883. 


22  LECTURES   ON    NERVOUS   DISEASES. 

Tlio  hemiplegia,  which  follows  injury  to  the  corpus  striatum,  is 
conlined  chiefly  to  the  side  opposite  to  the  lesion  ;  in  cases  of  extreme 
rarity,  paralysis  of  motion  on  the  same  side  lias  been  clinically  recorded. 
Plechsig  has  proved  that  such  cases  are  to  be  interpreted  as  the  result 
of  an  individual  peculiarit}'  in  the  relative  niniiber  of  decussating  and 
direct  pyramidal  fibres  (Fig.  29). 

"  The  corpus  striatum,  like  the  optic  thalamus,  may  possibly  (as  Luys 
suggests)  be  considered,  as  a  territory  in  which  cerebral,  cerebellar,  and 
spinal  activities  are  brought  into  intimate  communication.  It  probably 
acts  as  a  'halting  place  for  voluntary  motor  impulses'  emitted  from  the 
cerebral  cortex.  It  enables  these  impulses  to  'become  modified  and  pos- 
sibl}'  reinforced  by  currents  derived  from  the  cerebellum;  and,  by  its 
efferent  fibres,  it  transmits  centrifugal  motor  impulses  along  the  projec- 
tion system  to  different  groups  of  cells  within  the  spinal  gray  matter, 
whose  individual  functions  they  tend  to  evoke.'" 

Luys  states  that  this  ganglion  probably  acts  as  a  condenser  and 
modifier  of  all  motor  acts  which  are  the  result  of  volition  ;  and  manifests, 
through  the  agency  of  its  satellites  (the  cells  of  the  anterior  horns  of  the 
gray  matter  of  the  spinal  cord),  the  outward  expressions  of  our  person- 
ality. Without  the  influence  of  the  cerebral  hemispheres,  it  is  also 
capable,  by  means  of  cerebellar  innervation,  of  governing  all  the  complex 
muscular  movements  required  in  maintaining  equilibrium  (coordinated 
movements).  Finally,  it  may  be  pi-esumed  to  "  possess  the  power  of 
analysis  of  cerebral  and  cerebellar  currents  received  simultaneously,  and 
of  materializing  them  by  the  intervention  of  its  nerve-cells,  projecting 
them  in  a  new  form,  amplified  and  incorporated  with  the  requirements 
of  the  general  organism." 

Experiments  made  upon  the  caudate  and  lenticular  nuclei  can  hardly 
be  said  to  have  afforded  results  which  can  be  miide  the  basis  for  positive 
deductions  respecting  the  functions  of  each.  Nothnagel  emplo^'ed  injec- 
tions of  chromic  acid  into  the  substance  of  each,  and  also  destroyed  them 
by  means  of  an  instrument  devised  for  that  purpose,  but  he  arrived  at  no 
positive  conclusions,  save  that  the  lenticular  nucleus  seemed  to  have  a 
more  decided  influence  upon  motion  than  the  caudate  nucleus,  Avhen  the 
nuclei  of  both  sides  were  simultaneously  destro3'ed.  Observations  in 
comparative  anatomy  seem  to  show  a  relationship  of  the  caudate  nucleus 
with  the  fibres  of  the  leg  and  of  the  lenticular  nucleus  with  those  of  the 
arm. 

Some  observers  claim  to  have  destro3'ed  the  entire  ganglion  without 
any  marked  disturbance  of  sensory  or  motor  phenomena.  Collected 
cases  of  lesions  confined  to  either  nucleus  fail  to  show  that  anj'  perma- 
nent symptoms  have  been  produced  which  are  diagnostic  of  such  lesions. 


THE   OPTIC    THALAMUS. 


23 


THE     OPTIC     THALAMUS. 

Efforts  jiave  been  made  by  some  of  the  later  anatomists  and  physi- 
ologists who  have  speciality  investigated  the  brain,  to  subdivide  the  gray 
matter  of  the  thalamus  into  circumscribed  masses  or  nuclei,  and  to  trace 
the  fibres  which  appear  to  arise  from  these  nuclei  to  special  regions  of  the 
brain  and  spinal  cord.  Among  the  most  attractive  of  these  attempts  may 
be  mentioned  that  of  Luys,  whose  views  will  be  subsequently  given  in 
detail.  Whether  clinical  research  and  physiological  experiment  will  con- 
firm all  of  these  attractive  theories,  and  place  them  upon  a  ground  as 
worth}^  of  credence  as  the  deductions  of  Broca,  Munk,  and  Ferrier  re- 
garding the  functional  attributes  of  other  parts  of  the  brain,  time  alone 


Fig.  8. — A  Diagram  of  thr  Nuclei  of  the  Optic  Thalamus  and  the  Converging  Fibres 
Associated  with  Them.  (After  Luys.)  1,  converging  fibre.s  of  posterior  convolutions; 
2,  same,  of  middle  convolutions;  3,  same  of  posterior  convolutions;  4,  4',  4",  cortical 
periphery  as  related  to  the  central  gray  masses;  5,  optic  thalamus;  6,  corpus  striatum;  7, 
anterior  {olfactory)  centre;  S,  middle  {optic)  centre;  9,  median  {sensitive)  centre;  10,  pos- 
terior {acoustic)  centre:  11,  central  gray  region;  12,  ascending  gray  fibres  of  visceral  inner- 
vation: 13,  gray  optic  fibres;  14,  ascending  sensitive  fibres;  1.5,  ascending  acoustic  fibres; 
16,  series  of  antero- lateral  fibres  of  the  spinal  axis  going  to  be  lost  in  the  corpus  striatum. 

can  decide.     They  are  opposed  to  many  of  the  conclusions  of  Meynert, 
Flechsig,  Wernicke,  Spitzka,  Starr,  and  others. 

"  According  to  the  researches  of  Luj'^s,  four  isolated  ganglions  may 
be  demonstrated  in  the  thalamus.  Arnold,  in  common  with  some  other 
anatomists,  has  recognized  three  of  these,  and  the  fourth  is  now  added 
by  the  author  quoted.  This  author  states  that  these  ganglia  are  arranged 
in  an  antero-posterior  plane,  and  form  successive  tuberosities  upon  the 
thalamus,  giving  that  body  the  appearance  of  a  conglomerate  gland. 


24 


LECTUllES   ON    NEliVOUS   DISEASES. 


'■'■  The  anterior  gaixjlion  ol'  Luys  (f^orpua  album  subrotundum)  is 
especially  prominent.  It  is  said  by  this  author  to  be  developed  in  ani- 
mals in  i)roporti<)n  to  the  acuteness  of  the  sense  of  smell.  By  means  of 
the  'taenia  semi-circularis,'  tiiis  ganglion  (according  to  tins  author)  may 
be  shown  in  the  human  species  to  be  connected  with  the  roots  of  the 
olfactory  nerve,  llespeeting  it,  he  says:  'Direct  anatomical  examination 
shows  that  there  are  intimate  connections  between  the  anterior  centre 


""^ekJ^ 


JVC^ 


Fig.  p. — A  Transverse  Section  of  the  Human  Brain  from  Before  Backward.     (After 

Flechsig.)  N  C,  caudate  nucleus:  N  C ,  the  tail  of  N  C,  cut  across  (the  aiiiyg-cfala); 
L  N,  lenticular  nucleus,  with  its  three  subdivisions  (/,  //,  ///);  77/,  o/>tic  thalamus  :  F, 
frontal  lobe;  TS,  temporal  sphenoidal  lobe;  O,  occipital  lobe;  Cls.  claustruiit ;  IK, 
thalino-lenticular  portion  of  internal  capsicle  :  K,  X'??ft' of  same;  IK',  caudo-lcnticular 
portion  of  same;  EK,  external  capsule,  lying  between  the  lenticular  nucleus  and  the  claus- 
xryxvn;  f,  fornix  cvA  across;  In,  insula,  or  island  of  Reil;  Op,  depth  of  Sylvian  fissure 
beneath  the  operculum;  jnc,  middle  commissure  of  the  thalamus;  pk,  posterior  horn  of 
lateral  ventricle;  a/t,  anterior  horn  of  same;  SI,  septum  luciduin. 


and  the  peripheral  olfactory  apparatus.  On  the  other  hand,  in  confirma- 
tion of  this,  in  the  animal  species,  in  which  the  olfactory  apparatus  is 
very  mnch  developed,  this  ganglion  itself  is  proportionally  very  well 
marked.      Analogy  has  thus  led  us  to  conclude  that  this  ganglion  is 


THE    OPTIC   THALAMUS.  li,) 

in  direct  connection  witli  the  olfactory  impressions,  and  tliat  this  marks 
it  as  the  point  of  concentration  toward  wliich  they  converge  before  being- 
radiated  toward  tlie  cortical  periplier^.' 

"The  second  or  middle  centre  is  in  apparent  continuity,  according 
to  Lnys,  with  the  fibres  of  the  optic  tract.  He  considers  it  on  the 
same  grounds  as  those  previously  quoted  respecting  the  anterior  centre, 
as  a  seat  o1'  condensation  and  radiation  of  visual  impressions.*  There 
seems  to  be  inidisputable  grounds  for  the  belief  tliat  the  thalamus,  the 
outer  geniculate  bodies,  the  anterior  cor})ora  quadrigemina,  and  the  cor- 
tex of  the  occipital  lobes  are,  in  some  way,  associated  with  the  percep- 
tions afforded  by  the  retina.     (Munlv,  Wernicke,  Monakow,  and  others.) 

'•  We  know  that  extirpation  of  the  eye  is  followed  by  more  or  less 
complete  atrophy  of  the  outer  genicuhite  body  of  the  oi)posite  side, 
although  the  inner  geniculate  body  seems  to  remain  unaffected.  The 
exi)eriments  of  Longet,  who  destroyed  the  optic  thalami  upon  both  sides 
without  being  able  to  note  any  impairment  of  vision,  or  influence  upon 
the  movements  of  the  pupil ;  and  those  of  Lnssana  and  Lemoigne,  who 
found  that  blindness  of  the  opposite  eye  followed  unilateral  destruction  of 
the  thalamus,  may  suggest  the  possibility,  in  the  former,  of  the  escape  of 
this  centre,  and,  in  the  latter,  its  destruction.  It  is  difficult  to  devise  any 
experiment  which  will  positively  settle  the  bearings  of  the  thalamus  upon 
vision  ;  because  it  is  almost  impossible  to  destroy  special  portions  with 
accuracy,  or  if  this  were  insured,  to  avoid  injury  to  adjacent  structures. 
Fournie  claims  to  have  ettected  the  separate  annihilation  of  the  special 
senses  of  smell  and  vision  by  injections  made  into  difierent  parts  of 
the  thalamus  of  animals  ;  and  his  experiments,  if  subsequently  verified, 
will  tend  to  confirm  some  of  the  theories  advanced  by  Luys. 

''  Ritti  has  pointed  out  that  irritation  of  the  thalamus  may  pla}^  an 
important  part  in  the  development  of  hallucinations. 

''  The  third  centre  ('  median  ganglion '  of  Luys)  is  described  as 
about  the  size  of  a  pea,  and  situated  mathematically  in  the  exact  centre 
of  the  thalamus.  To  it,  the  discoverer  ascribes  the  function  of  presiding 
over  and  condensing  all  sensory  impressions. 

"  The  fourth  posterior  centre  is  stated  to  act  as  a  halting  place  and 
condenser  of  auditor'])  impressions.  Two  instances  where  the  brains  of 
deaf  mutes  were  found  to  present  a  localized  lesion  of  this  centre  are 
reported  by  Luys. 

"  The  views  here  expressed  are  quoted  on  account  of  their  origi- 
nality ;  and  because  the  author  of  them  ranks  high  as  an  authority  upon 

*Luys  states  that  it  is  scarcely  visible  in  those  animals  (the  mole  as  an  example) 
where  the  optic  nerves  are  rudimentary.  The  view  is  now  more  generally  accepted  that 
the  posterior  tubercle  of  the  thalamus  (the  pulviuar)  is  functionally  associated  with  the 
optic  fibres. 


26 


LECTUKES   ON    NERVOUS   DISEASES. 


the  subject  of  which  he  speaks.  The  numerous  cases  of  cerebral  hemor- 
rhage whicli  have  been  reported,  where  the  thahimus  was  apparently  the 
seat  of  localized  injury,  are  too  often  accompanied  with  a  clinical  history 
which  points  toward  pressure  upon  the  internal  capsule,  to  be  of  value 
as  confirmatory  evidence  of  the  existence  of  special  centres  in  the  thala- 
mus.* The  eflort  of  Lu^'S  to  adduce  cases  of  hemianaesthesia  in  support 
of  his  views  regarding  the  function  of  the  '  median  centre'  of  the  thala- 
mus, merely  because  a  lesion  of  that  ganglion  was  found  in  an  area 
defined  by  him  as  the  normal  limits  of  that  special  centre,  must  not  be 
deemed  conclusive;  because  the  same  effect  might  have  been  produced 
by  pressure  upon  the  fibres  within  the  posterior  third  of  the  internal 
capsule  of  the  cerebrum.     There  is  reason  to  hope,  and  possibly  to  be- 


FiG.  10. — Section  Across  the  Optic  Thalamus  and  Corpus  Striatum  in  the  Region 
OP  THE  Middle  Commissure.  (Shafer  after  a  preparation  by  Mr.  S.  G.  Shattuck  )  Natu- 
ral size,  t/i.,  thalamus  ;  a.,e.,  i.,  its  anterior,  external,  and  internal  nuclei  respectively  ;  a/,  its 
latticed  layer;  m.  c,  middle  commissure ;  above  and  below  it  is  the  cavity  of  the  third  ven- 
tricle; c.  c,  corpus  callosum  ;_/",  fornix,  separated  from  the  third  ventricle  and  thalamus  by 
the  velum  interpositum.  In  the  middle  of  this  are  seen  the  two  veins  of  Galen  and  the  choroid 
plexuses  of  the  third  ventricle;  and  at  its  edges  the  choroid  plexuses  of  the  lateral  ventricles; 
t.  s..  taeniae  semicircularis;  cr.,  forward  prolongation  of  the  crusta  passing  laterally  into  the 
internal  capsule,  i.  c:  s.  i.  r.,  subthalmic  prolongation  of  the  tegmentum,  consisting  of 
(1)  the  dorsal  layer,  (2)  the  zona  incerta,  and  (3)  the  corpus  subthalamicum  ;  j-.  «.,  substantia 
nigra;  n.  c,  nucleus  caudatus  of  the  corpus  striatum  ;  n.  I.,  nucleus  lenticularis  ;  e.  c,  ex- 
ternal capsule :  cl.,  claustrum;  /.,  island  of  Kiel. 


lieve,  that  sooner  or  later  isolated  ganglia  within  the  optic  thalamus  will 
be  demonstrated  to  exist  by  normal  and  pathological  anatomy,  as  well 
as  by  physiological  experiment ;  but  the  conclusions  even  of  so  promi- 
nent an  author  should  not  be  fully  accepted  without  further  testimony 
to  substantiate  their  accuraC3\  Some  of  the  later  observations  respecting 
the  optic  fibres,  seems  to  disprove  the  view  of  Luys. 

"  A  few  interesting  cases  have,  however,  been  brought  forward,  which 
certainly  seem  to  sustain  the  views  advanced.     A  case  reported  by  Hun- 

*  If  permanent  symptoms  remain  after  a  lesion  of  the  thalamus  is  suspected  to  exist, 
the  internal  capsule  is  probably  indirectly  involved.  (See  subsequent  pages  relating  to  the 
internal  capsule.) 


THE   OPTIC   THALAMUS.  27 

ter,*  where  a  youno;  woman  successively  lost  the  senses  of  smell,  sight, 
sensation,  and  hearing,  and  who  gradually  sank,  remaining  a  stranger  to 
all  external  impressions,  disclosed  at  the  autops^y  a  fungus  ha?matodes 
which  had  gradually  destroyed  the  optic  thalamus  of  each  side,  and  the 
optic  thalami  alone,  if  the  draAving  given  is  reliable.  Again,  Fournie's 
experiments  on  living  animals  points  strongly  to  the  existence  of  local- 
ized centres  in  the  thalamus.  Three  instances  of  unilateral  destruction 
of  smell,  observed  by  Yoisin  and  reported  by  Luys,  have  been  found  to 
be  associated  with  a  destruction  of  tlie  anterior  centre  of  the  thalamus. 
A  hemorrhagic  effusion  into  the  thalamus,  on  a  level  with  the  soft  com- 
missure (the  situation  of  the  optic  centre  of  LU3-S),  produced  (in  the  ex- 
perience of  Serres)  a  sudden  loss  of  sight  in  both  eyes.  Later  observa- 
tions seem,  however,  to  point  toward  a  relationship  between  the  poste- 
rior extremity  of  the  thalamus  (the  '■pulvinar'')  and  the  optic  fibres. 

"Ritti's  paper  upon  the  effects  of  irritation  of  the  thalamus  upon 
the  development  of  hallucinations,  lends  strength  to  the  view  that  that 
ganglion  in  some  way  regulates  the  transmission  of  sensory  impressions 
of  all  kinds  to  the  cerebral  cortex;  and  confii-ms  the  opinion  that  'the 
optic  thalami  are  to  be  regarded  as  intermediary  regions  which  are  inter- 
posed between  the  purely  reflex  phenomena  of  the  spinal  cord  and  the 
activities  of  psychial  life.' 

"  The  view  taken  by  Lussana  and  Lemoigne,  that  the  optic  thalami 
contained  motor  centres  in  animals  for  the  lateral  movements  of  the  fore- 
limbs  of  the  opposite  side,  seems  to  be  completel}"  overthrown  by  patho- 
logical statistics  in  the  human  race.  The  results  obtained  by  these  ex- 
perimenters are  also  at  variance  with  the  belief,  which  has  now  become 
general  among  neurologists,  that  the  thalami  are  intimately  connected 
with  the  sensory  tracts  of  the  cerebrum  and  cord ;  since  they  concluded 
that  no  evidence  of  pain  or  an^^  loss  of  sensibility  resulted  from  injury 
to  these  bodies. 

"  The  effects  of  all  experiments  on  animals,  howcA'cr,  agree  entirel}' 
with  the  general  experience  of  pathologists,  that  lesions  of  both  the 
thalamus  and  corpus  striatum  produce  results  upon  the  opposite  side  of 
the  body;  whether  the  symptoms  produced  point  to  a  disturbance  of  the 
kinesodic  (motor)  or  Jtsthesodic  (sensory)  tracts.  The  view  originall}^ 
advanced  by  Carpenter  and  Todd,  that  the  thalami  are  concerned  in  the 
upward  transmission  and  elaboration  of  sensory  impulses,  in  contradis- 
tinction to  the  corpora  striata,  which  are  concerned  in  the  downward 
transmission  and  elaboration  of  motor  impulses,  seems  to  be  gaining 
ground,  and  man}-  facts  may  be  urged  in  its  favor." 

The  experiments  of  Monakow  on  rabbits  lead  him  to  A'iews  not  en- 
tirely dissimilar  to  those  advanced   by  Luys.     He  places  the  cortical 

*  Mulico-Chirurg.  Trans.,  London,  1825,  vol.  xiii. 


28  LECTURES   ON   NERVOUS   DISEASES. 

connections  of  centres  in  tlie  tlial:iinns,  somewliat  difleren^ily,  however, 
from  the  conclusions  jilready  mentioned.  According  to  this  observer, 
the  posterior  tubercle  (the  pulvinar)  is  related  to  the  visual  tracts,  as  is 
also  the  external  geniculate  body  ;  the  internal  geniculate  body  is  related 
to  the  auditory  lil)res,  and  the  cortical  centres  of  heariug  in  the  first 
temporal  convolution ;  and  the  anterior  tubercle  and  median  nucleus 
are  related  to  the  frontal  lobes. 

The  pillars  of  the  fornix  seem  to  unite  the  thalamus  with  the  cor- 
tical centres  of  smell  and  taste ;  and,  according  to  Ferrier,  with  the  cor- 
tical centres  of  tactile  sensibility. 

Hemichorea  and  hemiathetosis  have  been  obserA'ed  in  connection 
with  lesions  of  the  thalamus;  but  they  must,  to  my  mind,  be  regarded  as 
an  evidence  of  irritation  of  the  motor  fibres  of  the  internal  capsule 
(wiiich  lie  closely  adjacent  to  the  thalamus).  Fig.  9  will  make  this  rela- 
tionship clear  to  the  mind  of  the  reader. 

TPIE    CAPSULAR   FIBRES   OF   THE   CEREBRUM.* 

Yertical  and  horizontal  cuts  made  through  the  cerebrum  exhibit  a 
well-defined  tract  of  fibres  in  each  hemisphere  which  separates  the  len- 
ticular  nucleus  from  two  other  gray  masses  of  the  same  hemisphere, 
viz.,  the  caudate  nucleus  and  the  thalamus. 

Tliis  tract  of  fibres  (inclosed  between  these  nodal  masses  of  cells) 
is  termed  the  '■'■internal  capsule,^''  because  it  bounds  the  lenticular  nucleus 
on  its  mesial  aspect.  A  similar  tract  of  fibres  also  separates  the  len- 
ticular nucleus  from  the  "claustrum"  of  the  same  hemisphere.  This  is 
known  as  the  "  external  cajjsule''^  (Figs.  7  and  9). 

The  fibres,  which  form  the  "internal"  and  "external  capsule"  of 
each  hemisphere,  seem  to  pass  through  the  substance  of  the  cerebrum 
without  any  structural  relationship  with  the  cells  of  the  caudate-  or  lentic- 
ular-nuclei, or  the  thalamus  (Flechsig).  In  this  respect  they  differ  from 
all  other  fibres  which  serve  to  connect  the  cells  of  the  cerebral  cortex 
with  collections  of  nerve  cells  outside  of  the  cerebrum. 

From  a  physiological  and  anatomical  standpoint,  the  fibres  of  the 
internal  capsule  possess  greater  interest  than  many  other  bundles.  Late 
researches  have  shown  that  it  contains  (1)  the  so-called  ^^ pyramidal 
fibres''''  (the  '■'■will  tracf''  of  Spitzka)  which  controls  voluntary  move- 
ments of  the  limbs;  (2)  the  so-called  ^^ sensory  tract,^''  whose  fibres  con- 
vey sensations  of  all  kinds  from  the  surface  of  the  body  to  the  cells  of  the 
cerebral  cortex  where  they  can  be  appreciated  by  consciousness ;  (3)  the 
so-called  ^'■speech  tract, ^^  whose  fibres  allow  of  communication  between  the 
"  speech  area  "  of  the  cortex  and  the  nuclei  of  origin  of  the  seventh,  tenth. 

*  This  term  is  a  misnomer.     These  fibres  form  a  capsule  to  the  "  lenticular  nucleus," 
properly  speaking,  and  not  to  the  cerebrum. 


CAPSULAR   FIBRES    OF   THE    CEREBRUM.  29 

eleventh,  and  twelfth  criinifil  nerves  (within  the  medulla);  (4)  the  motor 
fibres  of  the  faee ;  (5)  bundles  of  fibres  connected  with  the  special 
senses  (sight,  smell,  hearing,  taste,  and  touch);  (6)  the  so-called  '■'' hypo- 
glossal tract,''''  which  connects  the  cortical  centre  for  movements  of  the 
tongue  with  the  nucleus  of  origin  of  the  twelfth  cranial  nerve  within  the 
medulla;  finally,  many  other  bundles  of  fibres  (whose  functions  are  not 
yet  determined)  occupy  the  anterior  part  of  the  capsule  in  front  of  its 
"knee."     (Fig.  9). 

If  a  horizontal  cut  be  made  through  the  substance  of  the  cerebrum 
at  a  level  which  shall  include  the  basal  ganglia  (the  caudate  nucleus,  tlie 
lenticular  nucleus,  and  the  thalamus  of  each  hemisphere)  in  the  plane  of 
the  section,  we  shall  see  that  the  outline  of  the  internal  capsule  is  marked 
by  an  angle,  termed  the  "genu"  or  "knee"  of  this  capsule.  This  is 
shown  in  the  cut  of  Flechsig  (Fig.  9),  and  also  in  another  which  is  intro- 
duced later.  A  subsequent  diagram  off'ered  as  explanatory  of  some  of 
the  results  of  cerebral  hemorrhage  may  be  consulted  in  this  connection 
with  benefit  to  the  reader. 

That  portion  of  the  internal  capsule  Avhich  lies  between  the  len- 
ticular and  caudate  nuclei  has  been  named  the  '■'■  caudo-lenticular'''' 
portion  (Spitzka).     It  lies  anteriorly  to  the  "knee." 

The  part  posterior  to  the  "knee"  has  been  termed  by  the  same 
author  the  '■'•thalamo-lenticular''''  portion. 

In  studying  the  cut  of  Flechsig  (Fig.  9)  it  must  be  remembered 
(1)  that  the  fibrCvS  which  constitute  the  internal  capsule  pass  vertically 
to  the  plane  of  the  section ;  (2)  that,  above  the  upper  limits  of  the 
basal  ganglia,  they  radiate  to  different  areas  of  the  cerebral  cortex;  (3) 
that  the  component  fibres  of  the  capsule  may  be  subdivided  into  groups. 
The  functions  of  some  have  been  quite  positively  determined  of  late. 
Tiiis  has  been  done  by  a  study  of  their  apparent  cortical  distribution,  and 
of  secondary  degeneration  of  special  nerve  tracts  ;  by  an  analysis  of  the 
symptoms  produced  during  life,  when  well-defined  lesions  of  the  internal 
capsule  have  existed;  by  the  so-called  "development  method"  of  Flech- 
sig; and  by  the  effects  of  section  of  nerve  tracts  in  newly-born  animals 
(Gudden's  method). 

The  following  statements  seem  to  be  now  quite  well  established,  and 
to  be  of  service  as  clinical  guides  to  the  localization  of  cerebral  lesions 
wliich  directly  involve  or  create  pressure  upon  these  fibres. 

( 1 )  The  "  caudo-lenticular  "  portion  is  composed  of  fibres  whose  func- 
tion is  imperfectly  understood.  They  seem  to  pass  chiefly  to  the  cortex 
of  the  frontal  lobes. 

(2)  In  the  region  of  the  '■'•knee,''''  the  "thalamo-lenticular"  portion 
contains  the  motor  fibres  of  the  face. 

(3)  Posterior  to  the  facial  tract  lie  the  fibres  of  the  so-called  '•'■pyra- 


30  LECTURES   ON   NERVOUS   DISEASES. 

niidal  motor  tract'''  or  the  '■'■will  tract.^''  Those  of  the  arm  probably  lie 
anteriorly  to  those  destined  for  the  leg.  Lesions  affecting  this  part  would 
create  chiefly  a  hemiplegia  of  the  opposed  side.  These  fibres  constitute 
the  anterior  pyramid  of  the  corresponding  half  of  the  medulla  oblongata; 
hence  the  name  which  is  commonly  applied  to  them. 

(4)  Posterior  to  the  general  motor  fibres,  we  encounter  the  so-called 
^^ sensory  tract.'"  A  lesion  of  the  entire  bundle  would  induce  hemianees- 
thesia  of  the  opposed  side. 

(5)  Next  in  order  from  before  backward,  the  fibres  of  the  ^'■speech 
tract^''  are  supposed  to  pass  (Wernicke).  A  lesion  confined  to  this  bundle 
would  produce  aphasic  symptoms. 

(6)  Finally,  the  optic  Jibra  pass  through  the  extreme  posterior  part 
of  the  capsule.  Lesions  of  this  bundle  cause  "homonymous  hemian- 
opsia''' (the  blindness  being  confined  to  the  right  lateral  half  of  each  eye 
if  it  affect  the  right  capsule^  or  vice  versa). 

(*I)  The  course  of  the  fibres  associated  with  the  special  senses  of 
taste  and  smell  is  not  j'et  as  positively  determined,  as  in  the  case  of  the 
optic  and  auditory  fibres.  The  auditory  tract  probablj'  passes  through 
the  lower  and  posterior  part  of  the  internal  capsule.* 

(8)  The  hyjjoglossal  cerebral  tract  probabW  joins  the  lower  third 
of  the  precentral  gyrus  (ascending  frontal  convolution)  with  the  medul- 
lary nucleus  of  the  twelfth  cranial  nerve  by  passing  through  the  region 
of  the  "knee"  of  the  internal  capsule,  anteriorly  to  the  motor  fibres 
which  govern  the  limbs  (Raymond  and  Artaud).  Lesions  of  this  tract 
produce  symptoms  closely  allied  to  those  of  Duchenne's  disease  ("bulbar 
parah'sis  " — "  glosso-labio-laryngcal  paralysis  "), 

The  outlines  of  the  surfaces  of  the  thalamus  and  the  lenticular 
nucleus  of  the  corpus  striatum,  as  seen  in  all  vertical  sections  of  the  cere- 
lirum,  may  be  roughly  compared  to  the  form  of  a  square,  whose  two 
lialves  are  defined  by  a  diagonal  band  (the  "  internal  capsule,"-^)  run- 
liing  from  the  upper  and  outer  corner  to  the  lower  and  inner  corner. 
These  halves  correspond  to  the  respective  ganglia.  It  may  be  worthy' 
of  remark,  in  this  connection,  that  the  surface  of  the  thalamus,  which 
lies  in  contact  with  the  internal  capsule  of  the  cerebrum  marks  the  cen- 
tral or  receiving  pole  for  the  fibres,  which  join  it  with  the  cortex  of  the 
cerebral  lobes.     This  is  not  the  case  with  the  lenticular  nucleus. 

*Spitzka,  in  a  late  article,  states  his  conclusion  that  sound  is  transmitted  from  the 
cochlea  through  the  following  structures  to  reach  the  cortical  centres  of  hearing.  1,  the 
l)osterior  division  of  the  eighth  pair  ;  2,  the  trapezium  of  the  same  side — where  the  auditory 
fibres  cross  to  the  opposite  side ;  .3,  a  part  of  the  lemniscus ;  4,  the  posterior  pair  of  the 
corpora  quadrigemina ;  5,  the  internal  geniculate  body ;  6,  the  corona  radiata ;  7,  the  cor- 
tical centres  in  the  superior  temporal  gyrus.     (See  also  foot-note  on  page  42.) 

f  This  bundle  of  fibres  ceases  with  the  posterior  limits  of  the  lenticular  nucleus  of  the 
eorpus  striatum. 


THE   CRUS    CEREBEI.  31 

The  external  surface  of  the  thalamus  (which  lies  in  contact  witli  the 
internal  capsule  of  the  cerebrum)  presents  a  peculiar  appearance,  which 
has  given  it  the  name  of  "  lattice  layer  "  (Kolliker).  All  along  this  surfti-ce, 
radiating  fibres  pass  out  of  the  thalamus  to  become  intermingled  with 
the  fibres  of  the  internal  capsule,  and  to  be  distributed  to  the  cerebral 
cortex.  Those  from  the  front  of  the  ganglion  pass  to  the  frontal  lobe ; 
those  from  the  middle  are  distributed  to  the  posterior  part  of  the  frontal 
and  to  the  parietal  and  temi)oro-sphenoidal  lobes ;  those  from  the  pos- 
terior part  can  be  traced  to  the  temporo-sphenoidal  and  occipital  lobes. 
From  the  region  of  the  pulvinar,  or  posterior  tubercle,  fibres  can  be 
traced  into  the  optic  tract. 

The  internal  capsule  will  be  considered  in  its  clinical  aspects  in 
subsequent  pages  of  this  section,  and  also  in  connection  with  the  S3^mp- 
tomatology  of  cerebral  apoplexy.  Diagrams  will  then  be  given  which 
will  help  to  make  the  subject  clear  to  the  reader. 

THE   CEUS    CEREBRI. 

The  stem  of  each  cerebral  hemisphere  (Fig.  1)  is  composed  of  fibres 
that  serve  to  connect  the  cells  of  some  of  the  component  parts  of  each 
cerebral  hemisphere  with  other  cells,  situated  either  within  the  cms  itself, 
the  pons  Varolii,  the  cerebellum,  the  medulla,  oblongata,  or  the  gray  matter 
of  the  spinal  cord.     These  fibres  are  therefore  of  different  lengths. 

The  shortest  fibres  of  the  crus  probably  terminate  in  the  gray  matter 
of  the  crus  (substantia  nigra  of  Soemmering,  and  the  red  nucleus  of  Still- 
ing, see  Fig.  11).  The  longest  fibres  terminate  in  the  lowest  segments 
of  the  spinal  cord. 

The  diagram  of  a  cross-section  of  the  crura  cerebri,  introduced  at 
this  point,  will  make  some  of  the  most  essential  points  in  their  archi- 
tecture apparent.  It  shows  the  gray  masses  of  each  crus  ;  and  also  the 
situation  of  several  different  nerve  tracts  cut  across. 

The  ^' tegmentum  cruris^^  lies  posterior  to  the  substantia  nigra.  It 
contains  the  fibres  designed  for  sensory  conduction  to  the  brain ;  and, 
possibly,  a  few  motor  filaments. 

The  "  crusta  cruris  "  (basis  cruris)  lies  in  front  of  the  substantia 
nigra.     It  is  chiefly  composed  of  motor  fibres. 

T\iQ  fibres  of  the  third  cranial  nerve  (motor  oculi)  traverse  the  crus 
(in  the  plane  of  the  section),  from  the  nucleus  of  that  nerve  in  the  gray 
matter  around  the  Sylvian  aqueduct  (iter  e  tertio  ad  quarto  ventriculo) 
to  its  point  of  exit. 

The  fibres  of  the  pyramidal  tracts  (see  Figs.  12  and  29)  occupy  but 
limited  area  in  the  crusta  cruris  (as  shown  in  the  diagram). 

The   red   nuclei   are  closely  related  to  the  fibres   of  the  superior 


32 


LECTURES    ON    NERVOUS   DISEASES. 


peduncles  of  the  cerebellum*  (processus  e  cerebellu  ad  cerebrum),  and  the 
fibres  of  the  third  cranial  nerve.  Their  function  is  not  positively  deter- 
mined. Lesions  of  these  bodies  seem  to  create  symptoms  of  incoordi- 
nation of  movement  and  paralysis  of  the  third  cranial  nerve. 

This  diagram  (Fig.  11)  ma}' aid  the  reader  in  mastering  the  grounds 
for  many  clinical  deductions  respecting  lesions  of  the  crus,  which  will  be 
mentioned  later  in  this  section. 


^La-teral 
(  qroove 


3^M 


Fig.   11. A  Diagrammatic  Represkntation  of  the  Crura   Cerebri  in  Cross-section. 

(After  a  blackboard  drawing  by  the  Author.)  c.  q.,  corpora  guadrigemina  ;  S,  aqueduct 
of  Sylvius  (iter  e  tertio)  ;  4,  7iucleus  0/  the  fourth  cranial  nerve  in  the  gray  matter  which 
surrounds  the  aqueduct ;  3,  nucleus  of  the  third  cranial  nerve,  whose  fibres  are  depicted  : 
q.  I.,  root  of  fifth  cranial  nerve  :  p.  1.  i.,  posterior  longitudinal  bundle  :  R.  X.,  the  red 
nuclei  of  Stilling;  5^.  N.,  the  substantia  nigra:  P.  the  portion  of  the  "crusta"  occupied 
by  xV^  pyramidal  fibres  (Fig.  2S).  The  tract  of  the  fillet  or  "lemniscus,"  as  well  as  the 
relative  situation  of  the  "crusta"  or  "basis  cruris,"  and  the  "tegmentum  cruris"  is  also 
shown  in  the  cut. 

Respecting  the  formation  of  the  lemniscus  tract,  Flechsig  believes 
that  the  tract  is  composed  of  a  ver}"  large  bundle  (wdiich  degenerates 
downward)  and  a  smaller  one  (which  degenerates  upward). 

This  author  thinks  that  the  larger  bundle  arises  from  the  outer  body 
of  the  lenticular  nucleus  (Fig.  T),  and  he  places  its  termination  in  the 
olivary  body  of  the  medulla.  The  smaller  bundle  is  believed  by  this 
observer  to  start  in  the  sensory  decussation  at  the  lower  part  of  the 
medulla  and  to  terminate  in  the  corona  radiata  of  the  cerebrum. 

*The  termination  of  the  fibres  of  the  superior  cerebellar  peduncle,  after  their  associa- 
tion with  the  red  nuclei  of  the  tegmentum  (Fig.  14),  is  not  yet  determined.  Flechsig  be- 
lieves that  they  go  to  the  lenticular  nucleus,  or  radiate  in  the  corona  radiata  after  passing 
through  the  thalamus.  The  cells  of  the  "  substantia  nigra  "  are  deeply  pigmented,  giving 
to  it  a  blackish  color. 


THE   PONS   VAROLII.  33 

Spitzka,  who  bus  written  a  very  complete  and  lucid  article  upon 
this  tract  (see  bibliography)  differs  from  Flechsig  in  some  of  his  con- 
clusions. He  traces  the  "olivar}-"  bundle  of  Flechsig  to  a  spinal  origin^ 
and  the  smaller  bundle,  described  by  Flechsig,  beyond  the  sensory  decus- 
sation to  the  nuclei  of  the  columns  of  Goll  and  Burdach  of  the  opposite 
side.  These  nuclei  are  shown  in  Fig.  37.  which  also  illustrates  Aeby's 
views  respecting  the  "'lemniscus  tract." 

The  close  proximity  of  the  corpora  quadri(/emina  to  the  tegmentum 
cruris,  leads  us  to  regard  blindness,  nystagmus,  strabismus,  and  an  ab- 
sence of  the  pupillary  i-eflex  (which  clinically  mark  a  lesion  of  the  an- 
terior ^jfltr)  as  strongly  diagnostic.  From  a  similar  train  of  reasoning, 
a  marked  disturbance  in  coordination  would  point  to  the  fact  that  the 
posterior  pair  were  involved,  or  that  the  red  nuclei  are  diseased.  A 
defective  action  of  homologous  branches  of  the  third  nerve  of  the  two 
sides  points  strongl}-  toward  a  lesion  of  the  latter  bodies. 

THE   PONS   VAEOLII. 

This  portion  of  the  brain  may  be  compared  (as  a  homely  illustra- 
tion) to  a  collar  around  the  crura,  which  helps  to  bind  the  cerebellar 
hemispheres  together,  and  to  tie  them  fast  to  adjacent  parts. 

As  was  the  case  with  the  crus,  cross-sections  made  through  the  pons 
reveal  (I)  isolated  gray  masses  (composed  of  nerve  cells)  in  great  abund- 
ance, and  (2)  distinct  bundles  of  fibres.  The  direction  of  these  fibres  may 
l)e  seen  to  be  both  horizontal  and  vertical. 

The  vertical  bundles  pass  into  the  substance  of  the  medulla  and 
spinal  cord,  and  are  extended  upward  to  the  cerebrum. 

The  horizontal  bundles  probably  serve  two  purposes:  (1)  to  connect 
the  tioo  cerehellar  hemispheres;  and  (2)  to  unite  each  cerebellar  hemi- 
sphere with  the  opposite  cerebral  hemisphere. 

The  number  of  fibres  which  compose  the  crus  is  very  largely  in  ex- 
cess of  that  which  exists  within  the  medulla ;  hence  we  are  justified  in 
assuming  (as  Me^-nert  first  suggested)  that  many  fibres  derived  from  the 
cerebrum  are  deflected  within  the  pons.  A  certain  proportion  only  of 
the  cerebral  fibres  is  prolonged  to  the  spinal  cord.  Some  of  those  so 
prolonged  are  functionally  associated  with  the  transmission  of  motor 
impulses  from  the  cerebrum  to  the  muscles  of  the  extremities, — the  so- 
called  ^'■pyramidal  tracts^''''  because  they  form  the  "anterior  pyramids" 
of  the  medulla.  Others  convey  sensory  impressions  from  the  peripheral 
organs  to  the  cells  of  the  cerebrum, — the  so-called  '■'sensory  tracts.'''' 

The  gray  matter  of  the  pons  seems  to  be  composed  of  cells  that  serve 
to  interrupt  the  paths  of  communication  between  the  cerebrum  and 
cerebellum,  and  also  between  the  two  cerebellar  hemispheres. 

3 


34 


LECTURES   ON   NERVOUS   DISEASES. 


The  association  of  the  fibres  which  constitute  the  middle  peduncles 
of  the  cerebellar  hemispheres  with  the  ''cerebral  tracts"  (by  means  of  the 
multipolar  cells  in  the  pons)  is  a  crossed  one — the  left  cerebellar  hemi- 
sphere l)eing  joined  to  the  right  cerebral  strand,  and  vice  versa.  This  prob- 
ably brings  the  cerebellar  hemispheres  into  association  with  those  motor 
fibres  which  act  upon  the  corresponding  limb;  because  the  pyramidal 
fibres  decussate  to  a  great  extent  at  the  lower  part  of  the  medulla. 


Spinal   Cord 


Fig.  12.— a  Diagram  Designed  by  the  Author  to  Illustrate  the  ComsE  op  Certain 
Nerve-Tracts  Within  the  Cerebrum,  Crus,  Pons,  Medclla,  and  Spinal  Cord. 
(Modified  from  P'lechsig.)  C.  N.,  caudate  nucleus;  L.  N.,  lenticular  nucleus;  O.  T.,  optic 
thalamus;  <;.  j^.,  gray  matter  of  the  pons  ;  /".  A'.,  fonmatio  reticularis  ;  C. />.,  corpus  denta- 
tum;  O,  olivary  body;  -V.  C,  clavate  nucleus;  7".  iV.,  triangular  nucleus;  C.  Q  ,  corpora 
quadrigemina ;  /.  C,  upper  limit  of  the  capsular  fibres;  »«,  >«,  m,  motor  centres  around  the 
fissure  of  Rolando;    cr..  fibres  of  the   "corona  radiata."      1,  the  "fyramidal  tract," 


THE   PONS   VAliOLII.  35 

arising  from  the  motor  centres  of  the  cerebrum  and  terminating  in  the  cells  of  the  anterior 
horns  of  the  spinal  gray  substance  (l.'i  and  14);  2,  3,  and  4,  fibres  connecting  the  cerebral  cor- 
tex, the  caudate  nucleus  and  the  lenticular  nucleus  with  the  gray  matter  of  the  potts  after 
decussation  (see  Fig.  37),  and  then  prolonged  as  6  and  7  to  the  cerebellum;  5,  fibres  of  the 
superior  cerebellar  peduncle ;  6,  7,  S,  9,  and  10,  show  by  their  colors  the  tracts  which  they  are 
associated  with,  as  well  as  their  origin  and  termination;  11  and  17,  the  "direct  cerebellar 
tract"  of  the  spinal  cord  (whose  probable  termination  is  not  correctly  shown  in  the  cut,  as  it 
probably  ends  in  the  vermiform  process);  12,  the /(?w;z/i'c'«r  or  "fillet"  />•«<■!',  connecting 
the  olivary  body  with  the  optic  thalamus  and  the  corpora  quadrigemina;  13,  the  cells  of  the 
cord  connected  with  the  direct  pyramidal  tract :  14,  the  cells  of  the  cord  connected  with  the 
crossed  pyramidal  tract :  1.5,  fibres  of  ihscoluum  of  Burdach,  terminating  superiorly  in  the 
triangular  nucleus  ;  16,  fibres  of  the  column  of  Coll,  terminating  superiorly  in  the  clavate 
nucleus:  19,  fibres  of  the  cord  which  terminate  in  the  so-called  "  reticular  formation" 
directly;  18,  fibres  of  the  ret.  fo7-tu.  going  to  the  cerebellum.  [The  reader  should  com- 
pare this  diagram  with  Figs.  36  and  37,  and  note  the  difference  in  the  course  of  the  sensory 
tracts  during  their  passage  through  the  medulla,  there  shown  both  in  profile  and  in  transverse 
section.  The  differences  between  the  diagrams  will  make  the  various  views  held  at  the 
present  time  more  apparent  than  a  verbal  description.  In  this  diagram  the  crus  is  intention- 
ally shown  as  distinct  from  and  not  related  to  the  pons,  in  order  to  bring  certain  tracts  of 
fibres  into  prominence.     Some  of  the  tracts  shown  in  this  diagram  decussate. — See  Fig.  37.] 

This  arrangement  probably  allows  of  an  aritomatic  action  of  the  cere- 
helium  ujwn  the  skeletal  muscles,  as  exhibited  in  the  maintenance  of  a 
fixed  attitude  (Spencer),  the  finer  feats  of  rhj'thm  (Spitzka),  and  diffi- 
cult acts  of  etpiilibrium.  Fig,  12  shows  in  a  diagrammatic  way  the  fas- 
ciculi that  are  deflected  in  the  pons  to  the  cerebellum,  as  well  as  other  im- 
portant bundles  of  nerve  fibres.  It  should  be  conti-asted  with  Figs.  15,  36, 
and  37,  since  each  will  aid  in  the  comprehension  of  the  other,  and  at  the 
same  time  illustrate  different  views  which  are  held  in  reference  to  the 
course  of  the  sensory  tracts  in  the  medulla. 

A  magnified  section,  made  through  the  pons  shows,  in  addition  to 
those  points  in  its  architecture  alread}^  referred  to,  (1)  the  fibres  of  the 
sixth  cranial  nerve  and  its  nucleus  of  origin  ;  (2)  a  part  of  the  trigeminal 
nucleus  ;  (3)  a  part  of  the  facial  nucleus  ;  (4)  the  superior  olivary  body ; 
(5)  the  posterior  longitudinal  bundle;  (6)  the  round  bundle  (fasciculus 
teretes) ;  and  many  other  points  whose  functions  cannot  be  described  here 
in  detail  (Fig.  13). 

The  reticular  formation  (Fig.  15)  is  divided  b}^  the  fibres  of  the 
hypoglossal  nerve,  into  a  median  area  (between  the  nerve  root  and  the 
raphse)  and  a  lateral  area  (h'ing  to  the  outer  side  of  the  nerve  root). 

The  former  area  is  chiefly  composed  of  medullated  fibres ;  while  the 
latter  contains  numerous  nerve  cells.  The  fibres  of  the  anterior  root- 
zones  of  the  spinal  cord  become  lost  chiefly  in  the  median  area,  accordino- 
to  some  observers ;  while  those  of  the  lateral  column  of  the  cord  prob- 
ably have  an  association  of  some  kind  with  the  cells  of  the  lateral  area. 

The  fibres  of  the  reticular  formation  appear  to  end,  in  part,  in  the 
substantia  nigra  of  the  crus  and  the  medullary  laminae  of  the  thalamus ; 
while  some  appear  to  join  with  a  bundle  of  fibres  from  the  red  nucleus 
of  the  tegmentum,  and  to  pass  through  the  posterior  part  of  the  internal 
capsule,  and  to  radiate  toward  the  cortex. 

The  posterior  longitudinal  bundle  (Fig.  11)  is  believed  by  Spitzka  to 
arise  in  the  deep  gray  of  the  corpora  quadrigemina,  and  to  unite  the  cells 
of  these  bodies  with  the  nuclei  of  the  fourth  and  sixth  nerves,  and  the 
nuclei  of  the  muscles  of  the  neck.     He  is  led  to  the  conclusion  that  it 


36 


LECTUKES   ON    NERVOUS   DISEASES. 


presides  over  the  autoiiuitic  relationship  between  tlie  movements  of  the 
head  and  the  visual  apparatus. 

Within  the  substance  of  the  pons,  those  fibres  of  the  facial  nerve 
which  are  prolonged  cephalad,  decussate.  The  level  of  this  decussation 
may  be  designated  by  an  imarjinary  line,  which  shall  connect  the  ap- 
parent oi'igins  of  the  fifth  cranial  nerves  (Gubler). 

Lesions  of  the  pons  above  the  line  of  Gubler,  which  affect  the  facial 
fibres,  produce  facial  paralysis  on  the  side  opposed  to  the  lesion,  and, 
when  below  that  level,  upon  the  same  side  as  the  lesion. 


so 


BVB 


Fig.  1.3. — A  Transverse  Section  Through  the  Pons,  on  a  Level  with  the  Roots  op  the 
Sixth  AND  Seventh  Cranial  Nerves  from  a  Nine  Months'  Embryo.  (Modified  from 
Erb  and  Ross.)  The  right  half  represents  a  section  made  a  little  lower  than  the  left.  TV., 
transverse  fibre-s  of  the  pons;  P,  pyramidal  fibres  (see  Figs.  12.  36,  and  ■il);  so.  superior 
olivary  body;  Z,  posterior  longitudinal  fasciculus;  /,  fasciculus  teretes  (round  bundle);  Rvi, 
root  of  abducens;  /??'//,  root  of  facial ;  (i/.  ascending  root  of  trigeminus.  (This  figure  shows 
well  the  interlacing  of  the  vertical  pyramidal  fibres  with  the  horizontal  [transverse]  fibres  of 
the  pons.)  R,  round  bundle;  B.  peduncle  of  cerebellum  ;  a,  r.,  upward  prolongation  of  the 
anterior  root-zone  of  the  spinal  cord  ;  a.  I.  c,  anterior  nucleus  of  the  facial  nerve ;  /.  /.  c, 
posterior  nucleus  of  the  facial  nerve. 


The  pyramidal  fibres,  the  fibres  of  the  sensory  tracts,  the  fibres  of 
the  so-called  "  speech  tract,"  some  of  the  facial  fibres,  and  also  of  the 
trigeminal  and  hypoglossal  nerves,  run  cephalad  through  both  the  pons 
and  tlie  crus  to  reach  cortical  centres  of  the  cerebrum.  For  this  reason, 
lesions  of  the  crus  or  pons  maj'  produce  symptoms  which  indicate  de- 
struction of  one  or  more  of  these  tracts.  Among  these  sym])toms  may  be 
mentioned  the  following  :  Hemiplegia,  hemiangesthesia,  facial  pals^-,  facial 
anaesthesia,  disturbances  of  speech,  paralj'sis  of  the  third  and  sixth 
cranial  nerves.  These  conditions  will  be  discussed  separately  in  subse- 
quent pages  of  this  section. 


THE    CEREBELLUM,  37 

THE     CEREBELLUM, 

Although  the  cerebrum  usually  overlaps  the  cerebellum  in  animals 
of  the  higher  types,  the  fact  that  it  does  not  do  so  is  not  necessarily  an 
indication  of  a  lower  grade  in  the  scale  of  development.  The  construc- 
tion of  both  the  cerebrum  and  cerebellum  becomes  more  Intricate  as  de- 
velopment progresses.  Benedict  has  advanced  the  view  that  in  criminals 
brains  the  cei'ebrum  did  not  overlap  the  cerebellum.  Statements  of  this 
kind  have  been  shown  by  Wilder  to  be  open  to  suspicion,  from  the  de- 
fective methods  employed  in  the  examination  of  the  brain.  The  contour 
of  the  brain  (when  hardened  in  situ  by  Wilder's  method)  presents  a 
marked  contrast  to  the  outlines  commonly  accepted  as  normal. 

This  ganglion  is  connected  with  many  other  component  parts  of  the 
brain  by  fibres  which  compose  three  pairs  of  processes,  called  the  in- 
ferior^ middle^  and  superior  peduncles  of  the  cerebellum. 

1.  The  fibres  which  compose  the  inferior  peduncle  {rei^tiform  body 
— processus  e  cerebello  ad  meduUam)  joins  the  cerebellum  to  the  medulla. 
Although  authorities  differ  respecting  its  formation,  it  probably  com- 
prises three, distinct  sets  of  fibres.  These  are  as  follows:  (1)  those  con- 
stituting the  direct  cerebellar  column  of  the  corresponding  lateral  half 
of  the  spinal  cord  ;  (2)  a  set  derived  from  the  olivary  body  of  the  opposite 
side  of  the  medulla;  (3)  a  set  derived  from  the  nucleus  of  Burdach^s 
column  of  the  same  side  of  the  cord. 

These  three  sets  carry  impressions  of  diff"erent  forms  of  sensation  to 
the  cells  of  the  cerebellar  coi-tex  and  the  corpus  dentatum  (a  collection 
of  cells  within  the  substance  of  the  cerebellum). 

The  cerebellum  receives,  therefore,  through  its  inferior  peduncle, 
two  centripetal  tracts  at  least,  one  derived  from  the  lateral  columns,  and 
the  other  from  the  posterior  columns  of  the  cord.  Spitzka  believes  that 
the  muscular  sense  is  conveyed  to  the  cerebellum  by  means  of  Clarke's 
columns,  acting  in  conjunction  with  the  direct  cerebellar  columns,  and 
the  tactile  sense  by  means  of  Burdach's  columns  and  the  olivary  nuclei 
of  the  medulla. 

The  fibres  of  the  direct  cerebellar  column  are  supposed  b}'  Starr  to 
connect  the  cerebellum  (indirectly  through  the  cells  of  Clarke's  column) 
with  the  thoracic  and  abdominal  viscera.  The  other  fibres,  according 
to  this  observer,  transmit  to  it  certain  impressions  of  the  tactile  muscular- 
sense  from  the  lower  and  upper  extemities. 

2.  The  fibres  which  compose  the  middle  peduncle  (processus  e  cere- 
bello ad  pontem)  assist  to  form  the  pons.  Its  fibres  are  probably  asso- 
ciated by  a  direct  communication  with  the  gray  masses  found  within  the 
pons.  Some  of  these  act  as  commissural  tracts  between  the  cerebellar 
hemispheres.  Others  are  probably  a  part  of  the  motor  and  auditory 
apparatuses. 


38 


LECTURES    ON   NERVOUS   DISEASES. 


The  fibres  of  the  slpkrioh  peduncle  (processus  e  cerebello  ad  cere- 
brum.) connect  the  cerebellum  with  the  higher  centres.  They  pass  into 
the  posterior  part  of  the  corpora  <inadrigemina  (optic  lobes),  converge 
beneath  these  bodies,  decussate  into  the  red  nuclei  of  Stilling  (Fig.  14), 
and  then  pass  to  the  cerebral  hemisi)here.  Their  termination  within 
the  cerebral  hemisphere  is,  as  yet,  a  matter  of  doubt.  Luys  believes  that 
they  pass  to  the  caudate  nucleus,  and  assist  in  charging  its  cells  when 
exhausted.  Meynert  considers  that  they  help  to  form  a  part  of  the 
motor  apparatus. 


Fig.  14. — A  Diagram  Designed  by  the  Author  to  Illustrate  the  Various  Sets  op 
Fibres  Comprised  Within  the  Cekebello-Spinal  System.  (Modified  from  Ross.) 
C  R.,  crusta  cruris;  T.  E.  G.,  tegmentum  cruris;  A.  S.,  aqueduct  of  Sylvius,  surrounded 
by  the  tubular  gray  matter ;  S.  N.,  substantia  nigra ;  R.  N.,  red  nucleus  of  the  tegmentum  ; 
G.  M.  P.,  anterior  gray  matter  of  the  pons  ;  C.  C,  cerebellar  cortex  ;  N.  D.,  nucleus  denta- 
tum  ;  O.  B.,  olivary  body;  C  N.,  clavate  nucleus;  T.  N.,  triangular  nucleus;  D.  C.  T., 
fibres  of  the  "direct  cerebellar  tract"  of  the  spinal  cord;  P.  R.  Z.,  fibres  of  the  "posterior 
root  zone"  of  the  same  :  G.,  fibres  of  the  "  column  of  Goll ;"  1,  cerebro-cerebellar  fibres  ;  2, 
fibres  from  the  red  nucleus  of  the  tegmentum  to  the  dentate  nucleus  of  the  cerebellum  ;  .3,  fibres 
from  the  red  nucleus  to  the  cerebellar  cortex  ;  4,  fibres  from  the  cerebellar  cortex  to  the  den- 
tate nucleus  ;  5,  fibres  from  the  dentate  nucleus  to  the  olivary  body  of  the  opposite  side  ;  6, 
fibres  Irom  the  cerebellar  cortex  to  the  olivary  body  of  the  opposite  side;  7,  fibres  from  the 
cerebellar  cortex  to  the  anterior  gray  nucleus  of  the  pons  of  the  opposite  side  ;  8,  fibres  of  the 
direct  cerebellar  tract ;  9,  fibres  connecting  the  clavate  nucleus  and  the  olivary  body  of  the 
same  side  ;  10,  fibres  connecting  the  triangular  nucleus  and  the  olivary  body  of  the  same  side  ; 
11,  fibres  passing  from  the  olivary  body  to  the  horns  of  spinal  gray  matter  ;  12,  fibres  passing 
from  the  anterior  gray  matter  of  the  pons  to  the  horns  of  spinal  gray  matter  ;  13,  fibres  passing 
from  the  red  nucleusof  the  tegmentum  to  the  anterior  horns  of  the  spinal  gray  matter  ;  14,  fibres 
escaping  from  the  spinal  cord  through  the  anterior  root  of  a  spinal  nerve;  15,  fibres  of  the 
posterior  root  of  a  spinal  nerve,  entering  at  the  posterior  horn  of  the  spinal  gray  matter.  The 
dots  in  the  cut  end  of  the  spinal  cord,  near  to  15,  indicate  the  relative  position  of  the  dif- 
ferent tracts  with  which  they  are  connected.  A,  A,  A,  represent  fibres  which  are  destined  to 
connect  different  convolutions  of  the  cerebellar  cortex  (fibrae  propriae). 


THE   CEREBELLUM.  39 

That  the  red  nucleus  has  no  direct  connection  with  the  sensory 
tracts  of  the  central  nervous  system,  seems  to  be  proven  by  the  fact  that 
lesions  of  that  nucleus  tend  rather  to  disturb  coordination  of  movement 
(probably  by  disturbing  the  relationshiiD  between  the  nucleus  and  the 
cerebellum)  than  the  conduction  of  sensory  impulses.  Atrophy  of  one 
cerebellar  hemisphere  is  always  accompanied  by  a  similar  change  in  the 
opposed  red  nucleus. 

Spitzka  regards  the  cerebellum  as  an  "informing  depot,"  by  which 
the  cerebrum  is  made  cognizant  of  "  the  relations  which  the  body  bears 
to  time  and  space."  This  author  believes  that  all  rh3'thmic  movements 
(such  as  dancing,  etc.)  and  skillful  feats  of  equilibrium  are  presided  over 
by  this  ganglion.  Mitchell  is  led  to  think  that  the  cerebellum  is  simply 
a  storage  reservoir  for  nerve  force. 

It  is  stated  by  different  observers  that  some  filaments  of  the  nerves 
of  hearing  (eighth  l)air),  and  of  the  trigeminal  (fifth  pair),  the  motor  oculi 
(third  pair),  the  abducens  (fourth  pair),  and  the  pneumogastric  (10th 
pair),  can  be  traced  (directly  or  indirectly)  to  the  cerebellum. 

The  masses  of  gray  matter  comprised  within  the  cerebellum  (which 
have  been  specially  named)  comprise  (1)  the  cerebellar  cortex;  (2)  the 
"■nucleus  of  the  ventricular  roof''  (Spitzka)  or  the  nucleus  fastigii;  (3) 
i\ie  nucleus  emboliforrtiis ;  (4)  the  nucleus  glohosus;  and  (5)  the  corpus 
dentatum. 

I  quote  from  a  lecture  of  mine,  published  by  the  Medical  Record 
some  years  ago,  the  following  paragraphs,  subject  to  some  corrections  : — 

"  From  a  standpoint  of  our  present  knowledge,  the  cerebellum  must 
be  considered  as  the  '  terra  incognita '  of  the  brain.  The  clinical  evidence 
is  discordant.  The  anatomical  connections  of  the  cerebellum  with  other 
parts  of  the  nervous  system  are  remarkable,  and  their  minute  structure 
is,  as  3^et,  imperfectly  understood.  The  region  overlapped  by  the  cere- 
bellum is  interspersed  with  important  collections  of  gray  matter,  which 
act  as  nuclei  of  origin  for  important  nerve  tracts  ;  so  that  all  experiments 
made  upon  the  cerebellum  itself  or  its  peduncles  are  liable  to  cause  injury 
to  some  of  the  neighboring  parts,  and  thus  to  yield  results  which  are  puz- 
zling and  unreliable.  Conjecture  inevitably  forms  an  important  element 
in  all  of  the  theories  advanced  respecting  the  functions  of  the  ganglion 
itself,  or  of  certain  of  its  parts.  Nothnagel  claims  to  have  demonstrated 
that  mechanical  stimulation  of  the  surface  of  the  cerebellum  will  give  rise 
to  muscular  movement  without  signs  of  pain  being  perceived.  He  found 
that  these  movements  developed  slowly,  appearing  first  on  the  side  oper- 
ated upon  and  then  ceasing,  only  to  appear  upon  the  opposite  side.  He 
states  that  he  has  demonstrated  that  the  fifth,  fixcial,  and  hypoglossal 
nerves,  as  well  as  nerves  distributed  to  the  trunk  and  extremities,  can  be 
thus  called  into  action.     The  same  observer  concludes  that  destruction 


40  LECTUllES    ON    NERVOUS   DISEASES. 

of  the  rom))iiffSi(raI  fibres  and  the  vermis  produces  incoordination  of 
movement.  Hitzig  and  Ferrior  believe  that  injuries  to  the  lateral  lobe 
produce  tlie  same  varieties  of  'forced  movements'  as  are  noticed  after 
section  of  the  middle  peduncle.  Flourens  observed  that  injuries  to  the 
anterior  or  posterior  parts  of  the  vermis  caused  animals  to  fall  forward 
or  backward  respectively,  and  his  view's  have  been  confirmed  by  others. 
Ferrier  found  that  stimulation  of  the  cerebellar  cortex,  by  the  inter- 
rupted electric  current,  produced  lii  monkeys,  cats,  and  dogs  movements 
of  the  eyeballs,  with  associated  movements  of  the  head,  limbs,  and  pupils. 
Adamuck  produced  the  same  effects,  however,  by  stimulating  the  corpora 
quadrigemina.  Hitzig  refutes  the  view  that  Ferrier's  results  were  due  to 
an  escape  of  the  current  by  claiming  to  have  produced  similar  effects  by 
mechanical  irritation  of  the  cortex.  Eckhard  has  brought  forward  facts 
which  tend  to  show  that  in  certain  parts  of  the  cerebellum  lesions  tend  to 
produce  diabetes  or  simple  hydruria,  thus  resembling  the  effects  of  irrita- 
tion of  the  medulla  in  the  region  of  the  floor  of  the  fourth  ventricle. 

"  la  the  face  of  this  conflicting  mass  of  experimental  evidence,  I 
mention  now  one  of  the  most  plausible  and  attractive  tlieories  respecting 
the  relation  of  the  cerebellum  and  cerebrum  to  muscular  contraction, 
which  has  been  advocated  by  Spencer  and  sustained  by  Hughlings-Jack- 
son,Ross,  and  others.  It  is  believed  by  these  authors  that  all  continuous 
tonic  muscular  contraction  is  governed  by  the  cerebellum,  and  the  alter- 
nate or  clonic  muscular  contractions  by  the  cerebrum,  in  so  fur  as  they  are 
required  to  maintain  a  posture  or  produce  a  change  in  attitude.  In  all 
efforts  to  maintain  an  attitude  (once  assumed  as  the  result  of  some  cere- 
bral impression  received)  the  cerebellum  holds  the  muscular  appai-atus 
in  its  proper  state  of  tonicity ;  but  when  the  attitude  is  to  be  changed, 
for  any  possible  reason  of  which  the  cerebrum  is  conscious,  the  proper 
muscles  are  relaxed  and  others  thrown  into  a  state  of  contraction  by 
means  of  the  higher  ganglion.  The  body  is  then  intrusted  to  the  influ- 
ence of  the  cerebellum  if  the  attitude  is  to  be  again  maintained.  Thus 
it  is  suggested  that  the  cerebellum  be  considered  as  capable  of  auto- 
matic action,  but  still  as  a  subordinate  to  the  cerebrum,  which  possesses 
the  power  of  overcoming  it  in  one  of  two  ways  •  First,  b^' increasing  the 
supply  of  nerve  force  to  certain  sets  of  cells,  then  under  the  influence  of 
the  cerebellum,  and  thus  altering  their  action  upon  muscles;  or  second, 
by  inhibiting  or  totally  arresting  the  cerebellar  influx  to  the  antago- 
nistic sets  of  muscles.  Both  are  designed,  according  to  this  view,  to 
act  either  automatically  or  in  unison,  but  the  cerebellum  is  the  servant 
of  the  cerebrum  to  do  its  bidding  when  required. 

"  It  will  be  at  once  perceived  that  this  theory  applies  to  the  complex 
ph3"siological  acts  of  walking ;  the  ])rolonged  maintenance  of  any  given 
posture  ;  the  transfer  of  the  centre  of  gravity ;  the  passive  state  of  groups 


THE   MEDULLA    OBLONGATA.  41 

of  muscles  ;  and  many  of  the  morbid  phenomena  observed  in  muscles,  as 
the  result  of  impairment  of  the  higher  nerve  centres.  It  will  be  impos- 
sible to  discuss  all  of  these  conditions  in  this  connection.  Hughlinos- 
Jackson  and  Ross  have  covered  the  more  important  points  in  their  works. 
If  we  form  our  views  of  the  physiolooical  functions  of  the  cerebellum 
purely  from  the  standpoint  of  the  anatomical  connections  which  that 
ganglion  is  known  to  possess,  we  cannot  but  agree  with  Bechterew  in 
some  of  the  conclusion  which  he  has  lately  advanced.  This  author  l)e- 
lieves  that  the  cerebellum  is  intimately  connected  with  three  organs 
which  tend  to  exert  an  influence  upon  equilibrium,  as  folloAvs  :  First,  the 
semicircular  canals,  connected  with  the  organ  of  hearing;  second,  the 
organ  of  sight,  since  the  movements  of  the  globe  of  the  eye  and  possiblv 
the  sense  of  vision  may  be  traced  to  a  relation  with  the  gray  matter  in 
the  floor  of  the  third  ventricle  and  subsequently  with  the  cerebellum; 
third,  the  olivary  gray  matter,  which  this  author  thinks  is  probably  con- 
nected with  the  organs  of  tactile  sensibility. 

"The  views  of  this  author  have  been  in  part  anticipated  and  sus- 
tained by  Spitzka,  who.  in  an  article  published  some  years  ago,  con- 
siders the  cerebellum  as  the  centre  where  'impressions  of  touch  and  po- 
sition are  associated  with  those  of  time  and  space,'  and  hence  the  seat  of 
coordination  of  the  most  delicate  forms  of  movements  ;  such  as  are  neces- 
sary, for  instance,  'to  the  proper  adjustment  of  the  drum-membrane  of 
the  ear  for  the  correct  appreciation  of  sounds,  the  appreciation  of  time 
and  rhythm,  and  the  finer  acts  of  equilibrium.'  In  filling  this  position, 
the  latter  author  believes  that  the  cerebellum  is  subordinate  to  the  cere- 
brum, to  which  it  acts  as  an  'informing  depot"  for  coordination,  rather 
than  as  a  distinct  centre." 

THE   MEDULLA   OBLONGATA. 

Space  will  not  allow  of  a  description  of  the  architectural  details  of 
this  very  intricate  structure.  Its  component  parts  may,  however,  lie  thus 
classified:  1.  Certain  fibres  which  are  known  to  pass  without  interruption 
through  its  substance ;  thus  joining  the  cerebrum  or  cerebellum  with  the 
spinal  cord.*  2.  Other  fibres  which  arise  within  the  medulla  from  the 
cells  of  its  ditterent  nuclei.  3.  Collections  of  gray  matter,  which  are 
analogous  to  w^ell  defined  parts  of  the  spinal  gray  matter.  4.  Collections 
of  nerve  cells  which  are  destined  for  special  cranial  nerve  roots ;  these 
have  no  analogue  in  the  spinal  gray  substance. 

*The  "direct  cerebellar  fibres"  first  appear  in  the  second  or  third  lumbar  seoment, 
and  are  continued  upward  to  the  inferior  peduncle  of  the  cerebellum.  The  cells  of  Clarke's 
column  are  multipolar  and  much  smaller  tlian  those  of  the  anterior  horns.  According-  to 
Ross  and  Gaskell,  the  homologues  of  these  cells  are  observed  in  the  nucleus  of  the  vaous 
nerve  (Fig.  15). 


42 


LECTURES   ON    NERVOUS   DISEASES. 


Under  heading  (1)  inav  be  enumerated:  the  motor  or  "pyramidal 
tracts"  (direct  and  crossed);  the  so-called  "sensory  tracts"  to  the  cere- 
brum; and  the  "direct  cerebellar  tracts"  formed  indirectly  through  the 
agency  of  the  cells  of  Clarke's  column  within  the  spinal  cord. 


Fiu.  15. 


Fio.  16. 


a  he  de  fa 

vvv 

V    S    K 


Fig.  \5. — Diagram  of  the  Chtrf  Tracts  in  the  Medulla.  (After  Erb. )  (The  formatio  reticu- 
laris is  represented  by  shading.)  (9/.,olivary  body ;  /',  anterior;  ..S,  lateral,  and  //,  poster ior 
spinal  funiculi;  «,  pyramido-anterior  tract ;  ^/.pyramido-lateral  tract ;  /^.pyramidal  tract;  b, 
remainder  of  anterior  column  ;  c,  remainder  of  the  lateral  column  ;  <■,  e,  cerebello-lateral  tract ; 
y,  funiculis  gracilis  ;  andy,  nucleus  of  the  same;  g-,  funiculus  cuneatus,  and  ^'.nucleus  of  the 
same;  P.c.i.,  internal  fasciculus  of  the  pedunc.  cerebelli  ;  P.c.c.,  external  fasciculus  of  the 
same  :  Cq.F.,  tract  from  corp.  quadr.  to  format,  retic.  ;  Cq.  O  the  same  to  the  olivary  body  ; 
Thai.,  tract  from  the  thalamus  opticus. 

Fig.  16. — Tkan.sparent  Lateral  View  of  the  Medulla,  Showing  the  Relative  Posi- 
tions OF  THE  Most  Important  Nuclei;  Right  Half  of  the  Medulla,  Seen  from 
THE  Surface  OF  Section  ;  the  Parts  that  Lie  Closer  to  this  Surface  are  Deeper 
Shaded.  (After  Erb. )  /^,  pyramidal  tract  :  /^.  A>,  decussation  of  pyramids  ;  C',  olivary 
body;  C.  J,  superior  olivary  body  ;  ?',  motor,  /',  middle  sensory,  Z'",  inferior  sensory  nucleus 
of  trigeminus  ;  ?'/,  nucleus  of  abducens  ;  GJ",  genu  facialis;  /'//,  nucleus  facialis;  I'JII, 
posterior  median  acoustic  nucleus;*  /.A",  glosso-pharyngeal  nucleus;  A',  nucleus  of  vagus; 
JCI,  accessorius  nucleus  ;  XII,  hypoglossal  nucleus ;  Kz,  nucleus  of  the  funiculus  gracilis ; 
R  V,  trigeminus  roots  ;  those  of  the  li  I '/,  abducens,  and  li  KlI,  facialis. 

♦Respecting  the  auditory  nerve  roots,  Spitzka  believes  that  tlie  posterior  auditory 
root  ie  the  direct  path  for  tlie  transmission  of  sound  impulses,  and  that  the  anterior  audi- 
tory root  is  a  path  for  the  transmission  of  impressions  which  assist  in  the  determination  of 
equilibrium.     Edinger  rather  inclines  also  to  a  somewhat  similar  view. 


THE   MEDULLA   OBLONGATA.  43 

Under  (2)  the  following  bundles  might  be  classed  :  The  fibres  which 
form  the  ''fillet"  or  "lemniscus  tracts;"  those  which  join  the  nuclei  of 
Goll's  and  Burdach's  columns  with  the  olivarj^  bodies ;  those  which 
pass  into  the  inferior  cerebellar  peduncles  from  the  olivary  bodies;  some 
fibres  of  the  formatio  reticularis  ;  the  hypoglossal,  facial,  and  trigeminal 
cerebral  tracts;  the  so-called  "speech  tract,"  etc. 

Regarding  the  ultimate  distribution  of  the  fibres  of  the  lemniscus 
tract,  a  wide  diversity  of  opinion  between  authors  of  note  exists.  Flech- 
sig  believes  that  its  sensory  fibres  pass  lateral  of  the  red  nucleus,  then 
into  the  posterior  third  of  the  internal  capsule,  then  to  the  centrum  ovale, 
and  that  they  end  in  the  cortex.  Others,  among  whom  may  be  men- 
tioned Wernicke,  Forel,  and  Roller,  believe  that  they  end  in  the  medul- 
lary laminae  of  the  thalamus.  Others  again  trace  fibres  from  this  tract 
to  the  corpora  quadrigemina.     (See  also  paragraphs  on  page  32.) 

Under  (3)  and  (4)  come  the  nuclei  of  the  cranial  nerves  ;  the  olivary 
bodies;  the  cells  of  the  "formatio  reticularis;"  the  nuclei  developed  at 
the  upper  end  of  Goll's  and  Burdach's  columns ;  and  the  accessor^" 
olivary  bodies.  The  two  diagrams  of  Erb  which  are  introduced  here  will 
aid  the  reader  in  gaining  a  conception  of  the  situation  and  extent  of  tlie 
more  important  nuclei,  and  the  course  of  some  of  the  tracts  of  fibres 
mentioned.  ^  It  may  be  well,  for  one  not  familiar  with  the  subject,  to 
compare  them  with  Fig.  13,  and  also  with  a  section  of  the  spinal  cord 
which  shows  the  situation  of  the  columns  spoken  of  (Fig.  32). 

Note  (particularl}-  in  Fig.  16)  the  situation  of  each  of  the  nuclei,  the 
peculiar  course  of  the  facial  fibres,  the  situation  of  the  olivary  body  and 
the  superior  olive,  the  enormous  length  of  the  inferior  sensory  nucleus  of 
the  fifth  cranial  nerve,*  and  the  situation  of  the  decussation  of  the  "  pyra- 
midal" or  motor  tracts. 

The  looping  of  the  fibres  of  origin  of  the  facial  nerve  around  the 
nucleus  of  the  sixth  cranial  nerve  in  the  medulla,  has  caused  some  ob- 
servers to  favor  the  view  that  these  fibres  are  associated  in  some  imper- 
fectly understood  way  witli  the  cells  of  that  nucleus. 

In  Fig.  15  the  reader  should  trace  separately  the  course  of  the  pyra- 
midal tract  (from  above  downward);  that  of  the  direct  cerebellar  tract 
(from  below  upward);  the  course  of  the  fibres  derived  from  the  nuclei  of 
the  columns  of  Goll  and  Burdach;  the  varions  tracts  that  terminate  in 
the  reticular  formation,  as  well  as  those  that  pass  through  it ;  and,  finally, 
the  fibres  of  the  cerebellar  peduncle. 

*The  trigeminus  nerve  is  known  to  possess  motor,  sensory,  and  vaso-motor  or  secre- 
tory fibres.  Spitzka  concludes  that  the  vaso-motor  fibres  spring  from  sub-ependymal 
nuclei ;  that  the  motor  root  arises  in  part  from  a  continuation  of  the  lower  facial  nucleus  ; 
and  that  the  sensory  root  can  be  shown  to  arise  from  cells  within  the  medulla,  the  cervical 
segments  of  the  spinal  cord,  and  the  cerebellum. 


44  LECTUllES    ON    NEKVOIS    DISEASES. 

Spitzka  coni[)ar('s  the  medulla  to  'a  liypertrophied  segment  ol'  the 
cord,  in  which  the  longitudinal  associating  fibres  outweigh  in  number 
and  length  those  of  any  other  spinal  segment."  He  considers  it  as  a 
ganglion  wliich  presides  over  all  rejlex  acts  in  which  rhyllnn  is  an  essen- 
tial factor. 

Regarding  tin;  course,  termination,  and  function  of  some  of  the  sen- 
sor}^ nerve  tracts  depicted  in  this  diagram,  it  may  be  well  to  state  that 
dirterences  of  opinion  exist  among  authors  of  note.  Whether  some  are 
first  deflected  to  the  cerebellum  (being  compelled  to  pass  through  the 
substance  of  that  ganglion  in  order  to  reach  their  termination  in  the  cor- 
tical centres  of  the  cerebrum)  is  still  an  open  question  (see  Figs.  12.  14, 
15,  3(i,  and  37). 

Respecting  the  effects  of  the  formation  of  the  fourth  ventricle  upon 
the  central  gray  masses,  Spitzka  remarks,  tliat  if  we  start  with  the  com- 
parison of  the  gray  substance  of  the  cord  to  a  capital  letter  H,  and  imagine 
the  vertical  branches  of  the  H  to  be  separated  posteriorly  till  they  become 
almost  horizontal,  the  anterior  horn  becomes  the  most  internal,  the  lateral 
cornua  intermediate  between  the  anterior  and  the  posterior,  and  the  pos- 
terior horns  the  most  external.  Thus  the  "motor  system"  is  to  be 
sought  for  nearest  the  median  line;  the  "mixed  system"  to  its  outer 
side;  and  the  "sensory  system"  becomes  the  outermost. 

The  same  author  remarks,  in  this  connection,  that  "  as  the  me- 
dian line  of  the  cord  becomes  changed  by  the  horizontal  expansion  of 
the  fourth  A-entricle  in  the  medulla,  we  may  surmise  that  the  more  axial 
muscles  will  be  represented  by  nuclei  situated  near  the  ventricular  floor, 
the  more  appendicular  muscles  further  away  from  it." 

Concerning  the  trigeminal  nerve  roots  and  their  nuclei,  he  also  makes 
the  following  suggestions:  "On  the  strength  of  the  law  of  segmental 
harmon}',  we  can  theoreticall}^  infer  that  the  part  of  the  trigeminus  origin 
situated  in  the  level  of  the  cervical  spinal  cord  corresponds  to  the  tem- 
poral cutaneous  branches,  which,  with  the  upper  cervical  nerves  that 
originate  at  the  same  level,  share  the  distribution  to  the  oceipito-temporal 
region.  That  part  which  is  in  the  level  of  the  hypoglossal  nucleus,  will 
presumably  correspond  to  the  distribution  of  the  lingual  branch  of  the 
fifth.  Further  forwai'ds  (cephalad)  in  the  level  of  the  facial  and  motor 
trigeminal  nuclei,  we  will  have  the  dental,  mental,  and  infra-orbital  dis- 
tribution projected,  and  in  such  a  way  that  the  nerves  of  the  ui)per  jaw 
Avill  be  above  that  of  the  lower.  Still  further  cephalad,  in  the  altitude 
of  the  oculo-motor  muscles,  will  be  the  centre  of  the  ophthalmic  distri- 
bution area." 

The  statement  is  now  generally  accepted  by  neurologists  as  proven, 
that  both  the  motor  and  sensory  tracts,  which  unite  the  cerebral  cortex 
with  the  cells  of  the  spinal  gra}^  matter,  are  functionallt/  associated  with 
both  sides  of  the  bodi/. 


THE   MEDULLA   OBLONGATA. 


45 


The  main  distribution  is  to  tlint  lateral  lialf  of  the  body  which  is 
opposed  to  tlie  cerebral  hemisphere  to  which  the  fibres  can  be  ultimately 
traced.  The  decussation  of  both  the  motor  and  sensory  nerve  tracts  is, 
therefore,  not  complete.  The  motor  fibres  decussate  at  the  lower  i)art 
of  the  medulla.  Some  of  the  sensory  fibres  (probably  those  which  pre- 
side over  the  so-called  ''muscular  sense")  decussate  also  in  the  medulla 
(called  by  Spitzka  the  "  piniform  decussation,"  because  it  occupies  a  cone- 
shaped  area  in  cross-sections  of  the  medulla  made  at  that  level).  Those 
tracts,  which  convey  sensations  of  pain,  touch,  and  temperature,  prob- 
ably decussate  within  the  substance  of  the  spinal  cord. 


Fig.  17. 

I    34'Z'S'6'  6  5243     \' 


Fig.  18. 
C         B 


LOWER  LIMIT  OF 
MEDULLA 


Fig.  17.— a  Diagram  Designed  by  the  Author  to  Show  the  Course  of  the  Fibres 
WHICH  Co.MPOsE  THE  SpiNAL  CoRD.  1,1',  direct  pyramidal  bundles  ;  2,  2',  crossed  pyra- 
midal bundles,  decussating  in  medulla;  3,  3',  direct  cerebellar  fibres;  4,4',  fibres  related  to 
"muscular  sense,"  decussating  in  medulla;  5,.")',  and  6,6',  fibres  related  to  the  appreciation 
of  touch,  pain,  and  temperature.  The  motor  bundles  (red)  have  a  dot  upon  them  to  repre- 
sent the  motor  cells  of  the  cord  (ant.  horn).  Note  that  the  red  fibres  escape  from  the  ante- 
rior nerve  root  (a.  r.)  and  that  the  sensory  bundles  enter  at  the  posterior  nerve  root  (/.  r.), 
which  have  a  ganglion  (g;)  upon  them. 

Fig.  is. — A  Diagram  of  the  Lower  Part  of  the  Medulla  (as  if  transparent)  to  Show 
THE  Decussation  of  THE  Motor  Bundles.  (After  Erb).  a,  the  non-decussation  bundle 
(direct  pyramidal  fibres) ;  b,  the  decussating  bundle  (crossed  pyramidal  fibres).  The  former 
occupy  the  column  of  Tiirck  (Figs.  19  and  29)  and  the  latter  a  portion  of  the  lateral  columns 
of  the  spinal  cord  (Figs.  19  and  29). 

The  ^^ reticular  formation''''  acts  probably  as  a  conductor  of  sensory 
impulses  of  pain  and  temperature  which  pass  cephalad  to  reach  the  cells 
of  the  cerebral  cortex  where  they  become  transformed  into  conscious  re- 
alities (Starr). 


46  LECTURES   ON   NERVOUS   DISEASES. 

The  lemniscus  tract  or  the  •'Jillet'"'  probably  conveys  impressions 
of  muscuhir  sense  to  the  cerebral  cortex,  after  the  fibres  related  to  that 
sense  have  decussated  in  the  medulla  (Starr)      (See  also  page  32.) 

The  pijramidal  fibres  in  the  medulla  tend  to  displace  in  a  backward 
and  outward  direction,  the  lil)res  which  probably  assist  to  form  the  an- 
terior root  zone  (Fig.  18). 

Spitzka  advances  the  view  that  the  nuclei  of  origin  of  the  .npinal 
accesso7nj  nerve  have  different  functions  ;  that  within  the  spinal  cord  is 
probably  designed  to  innervate  the  trapezius  and  the  sterno-niastoid 
muscles ;  the  inner  accessor}^  nucleus  is  associated  with  the  fibres  dis- 
tributed to  the  larynx,  and  may,  therefore,  according  to  this  observer, 
be  called  the  "nucleus  lar3mgeus;"  finally,  the  outer  accessory  nucleus 
is  termed  by  him  the  "  degiutitory  nucleus,"  because  it  apparently  shares 
in  the  motor  supply  of  the  muscles  of  deglutition. 

The  jMsterior  longitudinal  bundle  becomes  closel}'  intermingled  with 
the  interolivary  tract  in  the  medulla ;  hence  it  is  impossible  to  distin- 
guish these  fibres  below  the  level  of  the  pons. 

THE   DIAGNOSTIC   VALUE   OF    SOME    OF   THE    SPECIAL    SYMPTOMS    OF 
NERVOUS   DERANGEMENT. 

Some  three  years  since,  I  published  in  the  Medical  Record^  as  an 
abstract  of  lectures  delivered  b}'  me,  a  series  of  articles  which  discussed 
the  various  tests  that  have  to  be  made  at  times  by  a  neurologist  to  detect 
the  existence  of  organic  disease  in  the  brain,  the  spinal  cord,  and  the 
cerebro-spinal  nerves.  These  articles  will  be  reproduced  in  this  and  the 
following  section,  with  such  modifications  and  additions  as  subsequent 
reflection  and  experience  on  my  part  have  suggested  to  me.  A  por- 
tion of  the  matter  included  under  this  heading  constitutes  a  portion  of 
this  course  of  lectures.  They  were  delivered  in  the  New  York  Post- 
Graduate  Medical  School  and  Hospital,  and  also  before  the  classes  of  the 
Medical  Department  of  the  Universitj'  of  Vermont.  I  quote  from  them 
as  follows : — 

"  Before  the  various  tests  which  are  employed  by  the  specialist  in 
neurology  to  determine  the  existence  of  diseased  states  of  the  nerves  and 
muscles  are  separately  discussed  (as  they  will  be  in  Section  II.  of  this 
work),  it  may  be  necessar}'  to  hastily  summarize  a  few  of  the  more 
important  facts  in  nervous  symptomatology. 

"  Not  only  are  some  of  the  tests,  described  later,  complex  in  them- 
selves, and  therefore  difficult  of  comprehension,  but  they  would  be  abso- 
lutely useless  in  practice  if  the  clinical  bearing  of  each  were  not  clearly 
comprehended.  For  example,  a  physician  who  has  acquired  a  smatter- 
ing of  nervous  symptomatology-  may  be  called  upon  to  examine  a  patient 
who  gives  evidences  of  impairment  of  motor  power  in  some  part  of  his 


SPECIAL   SYMPTOMS    OF   NERVOUS    DEEANGEMENT. 


47 


bod\-.  This  paralysis  may  be  due  t(i  some  trouble  eithi'r  in  the  brain  of 
his  patient,  his  spinal  cord,  or  in  some  special  nerve.  If  in  the  brain,  the 
physician  is  called  upon  to  decide  (for  himself  at  least)  whether  it  is  sit- 


FiG.  19. — A  Diagram  Illustrating  the  Developjient  of  the  Different  Systems  of 
Fibres  IN  THE  Spinal  Cord.  (After  Flechsig.)  A,  section  at  level  of  3d  cervical  nerves  ;  B, 
at  level  of  oth  cervical ;  C,  at  level  of  6th  dorsal ;  D,  at  the  level  of  4th  lumbar  nerves.  1,  prin- 
cipal mass  of  anterior  columns  ;  2,  Burdach's  columns  :  3,  lateral  columns  ;  4,  lateral  bound- 
ary of  gray  substance  ;  .5,  columns  of  GoU  ;  H,  direct  cerebellar  columns  ;  7,  crossed  pyramidal 
columns  ;  7',  TUrck's  columns  ;  v,  anterior  roots.  Note  that  Tiirck's  columns  disappear  in 
D  ;  that  GoU's  columns  increase  in  size  from  below  upward;  that  the  direct  cerebellar  col- 
umns appear  in  C,  and  increase  in  size  in  B  and  A  ;  that  the  crossed  pyramidal  columns 
reach  the  surface  in  D;  and  that  the  shape  of  the  gray  substance  differs  in  all  the  sections. 
The  numerals  employed  in  the  cuts  indicate  the  order  of  development  of  the  various  parts 
designated.  It  will  be  seen  that  the  motor-tracts  of  the  cord  are  the  last  to  attain  their  com- 
plete development. 


48  LECTURER   ON   NERVOUS   DISEASES. 

uaU'd  in  (I)  the  coverino:s  of  the  brain,  (2)  the  extenuil  gray  matter  that 
invests  it  like  a  cap  (the  cerebral  cortex),  or  (3)  in  parts  more  or  less  dis- 
tant from  its  exterior.  It  is  important,  from  a  standpoint  of  prognosis 
and  treatment,  that  he  comes  to  some  definite  conclusion  also  regarding 
the  character  of  the  trouble.  If  the  disease  be  confined  to  the  spinal 
cord  of  the  patient,  it  becomes  necessary  for  the  physician  to  discrimi- 
nate again  between  affections  that  follow  separate  bundles  of  nerve  fibres 
(systematic  lesions  of  the  cord)  and  those  that  spread  transversely  from 
column  to  column  (focal  lesions  of  the  cord;;  and  to  decide  also  as  to  the 
height  of  the  lesion,  its  pathological  character,  and  the  special  regions 
that  are  affected  by  it.  Finally,  if  the  paralysis  be  due  to  some  spinal 
nerve,  the  possibility  either  of  brain  or  spinal  disease  must  be  excluded, 
and  tlie  cause  must  be  sought  for  along  the  course  of  the  nerve  whose 
function  is  impaired. 

Before  I  discuss  the  clinical  tests  of  nervous  diseases  in  detail,  I 
direct  the  attention  of  the  reader  to  some  extracts  from  the  chapters  on 
the  Diseases  of  the  Brain  and  Spinal  Cord  that  are  emljodied  in  the  third 
edition  of  my  worlv  on  'Surgical  Diagnosis." 

MOTOR   PARALYSIS. 

Anything  which  tends  to  impair  the  generating  power  of  the  nerve 
centres  or  the  conducting  power  of  nerve  fibres  may  produce  paralysis 
of  motion  or  sensation. 

"  Motor  paralysis  (when  due  to  a  lesion  affecting  the  cerebro-spinal 
axis)  can  result,  therefore,  from  any  condition  which  interferes  with  the 
motor  convolutions  of  the  brain,  or  the  nerve  fibres  which  start  from 
them  and  are  continued  as  the  so-called  '  motor  tract.'  The  latter  aid 
in  all  voluntarii  movements  of  the  extremities.  They  pass  through  the 
following  parts  successively:  (1)  The  white  substance  of  the  cerebral 
hemispheres  ;  (2)  the  corpora  striata  :  (3)  the  crura  cerebri ;  (4)  the  pons 
Varolii ;  (5)  the  medulla  oblongata;  and  (6)  down  the  motor  columns  of 
the  spinal  cord. 

"  The  disturliing  lesions  may  be  therefore  classified  as  :  (1)  Those  of 
the  gray  matter  of  the  convolutions  of  the  brain  (cortical  lesions)  ;  (2) 
those  of  the  central  mass  of  the  cerebral  hemispheres,  including  lesions 
of  the  ••internal  capsule;*'  (3)  those  of  the  corpora  striata;  (4)  those  of 
the  crura  cerebri ;  (5)  those  of  the  pons  Varolii ;  (6)  those  of  the  medulla 
oblongata;  (7)  those  of  the  spinal  cord. 

"  The  various  tests  wliich  are  employed  to  determine  the  existence 
and  extent  of  a  loss  of  muscular  power  will  be  given  later." 


CORTICAL   PAEALYSIS   OR  SPASM.  49 

CORTICAL    PARALYSIS    OR    SPASM. 

These  may  be  dependent  upon  some  lesion  of  the  gra.3'  matter  of  the 
cerebral  convolutions  (the  cerebral  cortex).  They  may  occur  in  con- 
nection with  abscesses,  blood-clots,  spots  of  softening,  tumors,  depressed 
bone,  meningeal  thickenings  and  exudations,  embolism,  thrombosis,  etc 

The  researches  of  Ferrier,  Luciani,  Exner,  Horsley,  Beevor,  and 
others  have  lately  taught  us  the  situation  of  special  motor  centres  scat- 
tered over  the  convolutions  of  the  so-called  "  motor  area "  of  the  cere- 
brum. From  this  standpoint  we  are  often  enabled  to  judge  of  the  seat 
of  the  lesion  by  the  aid  of  the  groups  of  muscles  which  exhibit  the 
paralytic  state  (monoplegia).  Hughlings-Jackson  and  Brown-Sequard 
have  added  to  our  knowledge  of  the  relative  effects  of  destructive  and 
irritative  lesions  of  the  cerebral  cortex. 

"  Irritative  lesions  of  the  cei'ebral  cortex  are  usually  ushered  in  by 
convulsive  attacks,  which  leave  the  subject  paralyzed  in  some  special 
group  of  muscles  (monoplegia);  or,  if  hemiplegia  ensues,  some  parts  of 
the  body  are  more  affected  than  others.  The  paralysis  is  usually  tran- 
sient, and  returns  again  after  subsequent  convulsive  attacks.  These  irri- 
tative lesions  are  particularly  liable  to  be  of  syphilitic  origin. 

"  Destructive  lesions  of  the  cerebral  cortex  are  characterized  by 
paralysis  of  special  groups  of  muscles  (monoplegia,  or  mono-anaesthesia), 
as  was  the  case  with  the  irritative  lesions.  This  is  in  marked  contrast  to 
the  hemiplegia,  or  hemianaesthesia  which  follows  lesions  of  the  central 
portions  of  the  brain.  If  the  lesion  be  very  extensive  coma  may  be  pro- 
duced, but  consciousness  is  not  usually  lost  unless  the  attack  be  accom- 
panied by  convulsions.  Pain  of  a  local  character  within  the  head  is  often 
complained  of,  and  percussion  over  the  seat  of  the  lesion  frequentlj^  elicits 
it,  if  it  should  be  absent.  The  sensibility  of  the  paralyzed  parts  is  not 
impaired  unless  more  or  less  sensory  paralysis  exists  as  a  complication. 
The  paralyzed  muscles  exhibit  the  normal  electro-contractility.  As  is 
the  case  with  all  cerebral  lesions,  the  paralysis  is  developed  on  the  side 
opposite  to  the  exciting  cause  (except  in  very  rare  instances).  In  cor- 
tical lesions  of  the  motor  area,  the  muscles  frequentl>'  exhibit  a  state  of 
post-pai'alytic  rigidity  in  the  earl}'  stages  of  the  disease.  The  various 
tj'pes  of  monoplegia  and  the  surgical  guides  for  trephining  over  special 
motor  centres  have  been  discussed  in  the  Author's  work  upon  the  anatomy 
of  the  nervous  sj'stem. 

Horsley  has  lately  added  a  valuable  contribution  to  the  subject  of 
cortical  localization,  based  upon  experimentation  on  monkeys,  and  also 
on  observations  in  ten  cases  where  the  diseased  area  was  successfully 
determined  in  the  human  subject  prior  to  operative  procedure.  His  con- 
clusions are  therefore  worthy  of  note.  The}'  may  be  summarized  as 
follows : —  4 


50  LECTURES   ON   NERVOUS   DISEASES. 

1.  Sulci,  or  fissures^  are  not  to  he  regarded  as  accurate  boundaries  to 
cortical  areas,  although  they  constitute  valuable  landmarks  for  operative 
procedures  upon  the  cortex. 

2.  The  motor  centres^  according  to  this  observer,  are  capable  of 
further  suhdimsion  than  those  described  by  Ferrier,  and  they  overlap 
each  other  at  their  borders. 

3.  The  face  area,  taken  as  a  whole,  embraces  the  lower  third  of 
both  central  convolutions  (Fig.  4).  This  is  subdivided  into  (a)  an  upper 
and  anterior  portion,  which  controls  the  upper  part  of  the  face  and  the 
angle  of  the  mouth ;  {b)  the  anterior  half  of  the  lower  portion,  which 
gOA'erns  the  movements  of  the  vocal  cords  ;  and  (c)  the  posterior  half  of 
the  lower  portion,  which  governs  the  lower  part  of  the  face  and  the  floor 
of  the  mouth. 

4.  The  area  for  the  ujiper  limb  occupies  the  middle  third  of  both 
central  convolutions,  and  also  the  base  of  tlie  superior  and  middle  frontal 
convolutions.  It  joins,  and  also  merges  with,  the  area  for  movements  of 
the  head  and  neck  in  the  middle  frontal  gyrus,  and  with  that  of  the  leg 
in  the  superior  frontal  gyrus. 

In  the  area  described  as  pertaining  to  the  upper  limb,  the  uppermost 
part  is  thought  to  control  the  muscles  of  the  shoulder;  below,  and  pos- 
teriorl}',  the  elbow  is  represented  ;  still  further  below  and  somewhat  an- 
teriorly, the  wrist;  next  in  order,  anteriorly,  the  finger-movements  are 
placed,  and  lowest  of  all,  and  posteriorly,  the  thumb-movements  are 
located.  These  views  he  substantiates  by  observations  made  in  cases  of 
cortical  tumors,  where  spasm  was  developed  and  appeared  first  in  an 
isolated  region  of  the  upper  limb, 

5.  The  area  for  the  lower  limb  is  described  by  this  observer  as  em- 
bracing the  upper  portions  of  the  two  central  convolutions;  also  the 
whole  of  the  superior  parietal,  the  base  of  the  superior  frontal  convo- 
lutions, and  the  para-central  lobule.  This  description  is  not  materially 
different  from  that  of  Ferrier  (Fig.  3). 

The  subdivisions  of  this  area  are  as  yet  incompleted,  but  the  points 
given  are  of  interest  to  the  surgeon.  The  movements  of  the  big  toe  are 
referred  to  the  para-central  lobule ;  those  of  the  leg  alone  to  the  middle 
part ;  those  of  the  leg  and  arm  combined  to  the  most  anterior  portion. 
Most  of  these  conclusions  agree  in  the  main  with  those  of  Ferrier 
(Fig.  3). 

6.  The  area  for  movements  of  the  head  and  neck,  and  also  for  con- 
jugate deviation  of  the  eyes,  is  placed  by  this  observer  (in  common  with 
Ferrier  and  Munk)  in  the  bases  of  the  three  frontal  gyri  (see  12,  in  Fig.  3). 

7.  Respecting  the  steps  required  to  locate  the  fissures  of  Rolando 
and  Sylvius  upon  the  human  subject  during  life  (as  a  basis  for  surgical 
procedures)  the  following  conclusions  are  reached  : — 


CORTICAL  PARALYSIS  OR  SPASM.  51 

(a).  The  method  first  described  by  Thane  for  locating  Eolando\s 
fissure  is  adopted.  A  careful  measuremeat  is  first  made  along  the  mesial 
line  of  the  skull,  starting  from  the  root  of  the  nose  and  extending  to  the 
occipital  protuberance.  This  distance  is  then  halved.  The  fissure  of 
Rolando  at  its  upper  part  lies  one-half  inch  posteriorly  to  its  central 
point.  A  strip  of  flexible  iron  (with  a  movable  arm  placed  at  an  angle  of 
sixtA'-seven  degrees  to  it)  is  now  laid  upon  the  middle  line  of  the  head : 
the  point  of  junction  of  the  movable  arm  with  the  mesial  strip  being 
carefully  located  at  the  point  previously  determined  as  overlying  the 
upper  end  of  Rolando's  fissure.  When  this  is  accurately  done,  the 
movable  arm  marks  the  course  of  the  upper  two-tliirds  of  the  fissure  of 
Rolando,  but,  as  the  lower  third  tends  to  bend  sliglity  backward,  it  does 
not  as  clearly  define  the  lower  third  of  that  fissure. 

(6).  To  accurately  locate  the  fiasure  of  Sylvius  upon  the  skull  no 
little  precision  is  required.  A  few  points  in  the  bones  of  the  skull  have 
first  to  be  accurately  determined.  These  are  as  follows :  (1)  The  point 
where  the  temporal  ridge  crosses  the  coronal  suture  (the  '•'■  stephanion''''). 
This  can  usually  be  felt  with  the  finger,  the  coronal  suture  appearing  to 
the  touch  either  as  a  depression  or  as  a  ridge  lying  between  two  grooves. 
(2)  Exactly  midway  between  the  stephanion  and  the  upper  border  of  the 
zygoma,  on  a  line  drawn  vertical  to  the  zygoma  toward  the  stephanion, 
lies  another  point  known  as  the  "p/erto/r."  (3)  To  determine  the  highest 
point  of  the  suture  which  exists  between  the  squamous  portion  of  the 
temporal  bone  and  the  inferior  border  of  the  parietal  bone  (the  "  squamo- 
parietaV  suture)  a  measurement  has  to  be  made,  because  that  suture 
cannot  be  felt  beneath  the  temporal  muscle. 

In  front  of  the  temporo-maxillary  articulation,  an  upright  upon  the 
line  C-D  in  Fig.  20,  would  cross  the  zygoma.  The  junction  of  the  upper 
and  middle  thirds  of  the  measurement  made  upon  such  a  vertical  line 
between  the  upper  border  of  the  zygoma  and  the  ridge  formed  by  the 
temporal  muscle,  indicates  the  situation  of  the  highest  point  of  the 
squamo-parietal  suture. 

The  anterior  limb  of  the  Sylvian  fissure  starts  from  a  point  which 
lies  from  one-half  to  one  line  (one-twenty-fourth  to  one-twelfth  of  an 
inch)  in  front  of  the  '"pterion."  It  runs  anteriorly  and  upward  from 
that  point.  The  posterior  limb  passes  backward  and  slightly  upward 
from  the  same  point. 

8.  The  sulci  of  the  frontal  lobe^  and  also  the  inter-parietal  sulcus 
(which  limits  the  so-called  "motor  area"  of  the  cortex  posteriorly),  are 
next  to  be  located  upon  the  exterior  of  the  skull,  in  order  to  map  out 
the  convolutions.     The  guides  to  the  sulci  are  as  follows : — 

The  precentral  sulcus  lies  somewhat  behind  the  coronal  suture  and 
parallel  to  it.     It  extends  to  about  the  middle  of  Rolando's  fissure. 


52  LECTURES   ON   NERVOUS   DISEASES. 

The  inferior  fronlal  sulcus  diverges  from  the  precentral  at  about 
the  level  of  the  temporal  ridge. 

Tlie  superior  frontal  sulcus  starts  at  a  i)oint  in  the  precentral  gj'rus 
somewhat  posterior  to  the  line  of  tlie  precentral  sulcus  if  continued 
upward.  The  exact  point  is  about  midway  between  the  fissure  of  Ro- 
lando, and  an  upward  continuation  of  a  line  in  the  direction  of  the  pre- 
central sulcus.  Its  altitude  in  the  cerebrum  is  slightly  above  the  level 
of  a  point  (midway  between  the  mesial  line  of  the  skull,  and  the  centre 
of  the  parietal  eminence)  which  designates  the  lower  limit  of  the  superior 
parietal  convolution. 

The  inter-jiarietal  sulcus  in  its  ascending  course  starts  from  a  point 
on  a  level  with  the  junction  of  the  middle  and  lower  thirds  of  Rolando's 
fissure.  It  turns  backward  on  a  level  situated  midway  between  the 
mesial  line  of  the  skull  (marked  by  the  longitudinal  fissure)  and  the 
centre  of  the  parietal  eminence. 

HEMIPLEGIA. 

This  condition  is  characterized  b}^  a  paralysis  of  motion  in  one 
lateral  half  of  the  body.  It  is  often  associated  with  more  or  less  anaes- 
thesia, but  it  may  exist  independently  of  it.  I  quote  from  a  previous 
article  of  my  own,  as  follows: — 

"  Hemiplegia  may  be  produced  by  any  lesion  which  interferes  with 
the  free  action  of  the  '  motor  tract'  of  fibres  during  their  passage  from 
the  motor  convolutions  of  the  cerebrum  to  the  columns  of  the  sjjinal  cord; 
and  lesions  of  the  spinal  cord  itself  (if  suflBcientl}'  high  up  and  restricted 
to  a  lateral  half  of  the  cord  on  the  side  which  corresponds  to  the  paral- 
ysis) may  also  induce  it. 

"  If  the  lesion  be  within  the  cavity  of  the  cranium  the  hemiplegia 
will  be  on  the  opposite  side  of  the  body ;  if  it  be  spinal  the  hemiplegia 
will  be  upon  the  same  side.* 

"  Hemiplegia  from  intracranial  lesions  may  be  the  result  of  embolism , 
thrombosis,  apoplexy,  softening,  abscess,  tumors,  comi)ression  of  the 
brain  from  traumatic  causes,  destruction  of  limited  portions  by  injury, 
general  pressui'e  from  inflammatory'  exudations,  etc. 

"  Consciousness  is  generally  lost  when  cerebral  hemiplegia  is  de- 
veloped. Convulsive  attacks  are  not  usually  present  at  the  onset  of 
the  i)aralysis.  The  paralysis  is  more  profound,  as  a  rule,  than  that  of 
cortical  lesions,  and  of  longer  duration.  Tlie  special  senses  are  not 
infrequently  involved  to  a  greater  or  less  degree.  Other  cranial  nerves, 
which  are  not  associated  with  the  special  senses,  may  also  give  evidence 
of  being  implicated  by  the  lesion.  The  facial  nerve  is  most  frequently 
affected. 

*This  rule  is  not  absolutoly  true,  but  the  exceptions  to  it  are  so  rare  that  it  is  a  safe 
one  to  follow  iu  clinical  deductions. 


CROSSED    AND   COMPLETE   PARALYSIS.  53 

"  By  means  of  anatomical  guides  the  seat  and  extent  of  an  intra- 
cranial lesion  may  often  be  determined  with  positiveness.  The  co-exist- 
ence of  impairment  of  sensation  with  motor  paralysis  is  a  valuable 
diagnostic  sign  that  the  exciting  lesion  is  within  the  substance  of  the 
bruin  and  not  upon  its  surface.  The  exceptions  to  this  rule  are  ex- 
tremely rare. 

''  The  localization  of  non-cortical  lesions  is  more  ditlicult  and  some- 
what less  certain  than  those  which  are  confined  to  the  cortex.  A  careful 
study  of  all  the  symptoms  presented  (when  combined  with  a  knowledge 
of  modern  cerebral  and  spinal  anatomy)  will  often,  however,  lead  to  the 
most  positive  deductions.  It  should  be  remembered  that  accuracy  of 
diagnosis  often  leads  to  success  in  treatment  of  disease,  and  in  no  case 
is  it  better  exemplified  than  in  the  nerve  centres." 

CROSSED  PARALYSIS. 

A  condition  in  which  the  face  or  some  organ  of  special  sense  gives 
evidence  of  an  impairment  of  a  cranial  nerve,  while  the  body  is  simul- 
faneously  rendered  hemiplegic  on  the  opposite  side,  is  termed  "  crossed 
paralysis" — the  "  paralysie  alterne"  of  the  French  authors.  We  owe 
much  of  our  knowledge  of  this  subject  to  Professor  Romberg,  of 
Berlin,  who  has  written  extensively  upon  it. 

"  The  more  common  forms  of  crossed  paralysis  are  named  from  the 
cranial  nerve  which  exhibits  an  impairment  of  its  functions.  They  are 
as  follows:  First  cranial  nerve  (olfactory)  and  body  t3'pe  ;  third  cranial 
nerve  (motor  oculi)  and  bod}"  t,ype ;  fifth  cranial  nerve  (trigeminus)  and 
body  type ;  seventh  cranial  nerve  (facial)  and  body  type.  They  will  be 
discussed  later. 

"  It  may  be  well  to  remark  in  this  connection  that  '  crossed  paral- 
ysis '  is  of  special  clinical  importance,  because  it  often  imparts  the  most 
positive  information  to  the  surgeon  in  regard  to  the  seat  of  the  intra- 
cranial lesion  which  has  produced  it." 

COMPLETE   PARALYSIS. 

When  a  lesion  is  situated  at  the  base  of  the  brain,  and  is  suffi- 
ciently large  to  involve  the  motor  fibres  of  both  hemispheres,  the  body 
ma\'  be  completely  paralyzed  below  the  head. 

"Various  cranial  nerves — chiefly  the  third,  fifth,  sixth,  and  seventh 
— are  liable  to  then  exhibit  the  effects  of  simultaneous  pressure  upon 
them ;  hence  the  general  paralysis  of  the  bod}'  is  apt  to  be  associated 
with  paralj'tic  symptoms  confined  to  the  face. 

"  Bilateral  spinal  lesions  when  situated  high  up  in  the  cervical 
region,  may  also  cause  a  form  of  complete  paralysis  of  the  body — the  so- 
called  'cervical  paraplegia.'" 


54  LECTURES   ON   NEKV^OUS    DISEASES. 

SENSORY   PARALYSIS. 

Tlie  sensation  of  special  parts  of  the  body  may  be  so  raodilied  bv 
lesions  of  the  nerve  centres  as  to  constitute  a  type  of  paralysis.  The 
various  forms  of  this  condition  may  exist  independently  of  motor  paral- 
ysis, or  may  co-exist  with  it.  The  tests  commonly  emplo^-ed  to  detect 
the  limits  and  degree  of  sensory  paralysis  will  be  given  later. 

"Sensory  paral^^sis  may  be  classified  as  follows:  (1)  Paralysis  of 
those  cranial  nerA^es  which  are  not  endowed  with  motor  attributes;  (2) 
paralysis  of  sensory  nerves  below  the  head.  The  lattci-  subdivision 
comprises  hemianaesthesia,  general  aniesthesia,  and  local  aiuesthesia. 


Fig.  20. — A  Diagram  Designed  by  the  Author  to  Illustrate  the  Regions  of  the 
Cortex  of  the  Brain  Associated  with  Special  Parts  of  the  Body,  as  a  Guide 
to  the  Seat  of  Destructive  Processes  in  Connection  with  Motor  Paralysis  or 
Spasm. — A,  B,  dotted  line  to  indicate  the  relative  depth  of  the  brain  in  the  anterior,  middle, 
and  posterior  fossae  of  the  skull ;  C,  D,  a  line  running  from  the  cusps  of  the  teeth  of  the  upper 
jaw  to  the  tip  of  the  mastoid  process  of  the  temporal  bone.  This  is  useful  as  a  base  line  from 
which  to  erect  vertical  lines,  by  careful  measurement  during  life,  which  shall  intersect  the 
different  centres  of  the  brain  Trephining  for  the  relief  of  monoplegia  and  aphasia  can 
thus  be  performed  with  scientific  accuracy.  The  circle  designated  in  the  diagram  as  the 
speech  area  is  related  only  to  the  motor  acts  required  in  speech.  It  has  no  relationship  to 
the  various  forms  of  sensory  aphasia. 

The  views  lately  advanced  by  Horsley  (p.  49),  seem  to  suggest  that  this  diagram  might 
be  modified  somewhat. 

"Among  the  various  clinical  evidences  of  lesions  which  artect  the 
sensory  nerve  tracts  of  the  brain  and  spinal  cord,  the  following  may  be 
mentioned  :  (1)  hyper seMheaia^  or  an  excitation  of  sensibility  ;  (2)  mumh- 
ness;  (S)  formication,  or  a  sensation  like  the  creeping  of  ants  ;  (4)  aboli- 
tion  of  sensation,  or  complete  ana^sthesia — this  condition  may  be  general 
or  local;  (5)  anosmia  and  hemianopsia ;  (6)  delayed  sensation,  as  is 
evidenced  by  a  perceptible  interval  of  time  between  the  contact  of  a 
foreign  body  with  the  skin  and  its  conscious  appreciation  by  the  patient 


HEMIANESTHESIA — NUMBNESS    AND   FORMICATION.  55 

when  the  e^-es  are  closed.     The  pricking  of  the  skin  with  a  needle  is  a 
test  commonly  employed  to  determine  the  latter  condition. 

"  Some  of  these  conditions  will  be  now  considered  in  their  more 
important  aspects.  Others  will  not  be  separately  described,  as  they 
wonld  require  too  much  space,  provided  such  a  resume  was  attempted." 

HEMIANESTHESIA. 

This  condition  is  characterized  by  a  loss  only  of  sensation  (not  of 
motion)  in  one  lateral  half  of  the  body.  It  is  often  associated  with  more 
or  less  marked  hemiplegia.  When  hemiplegia  and  hemianresthesia  exist 
upon  the  same  side  a  cerebi'al  lesion  may  be  strongly  suspected ;  when 
upon  opposed  sides^  a  spinal  lesion  probably  exists. 

The  tests  emplo^^ed  to  determine  the  existence  of  this  state  and  its 
degrees  of  intensity  are  the  same  as  those  employed  in  any  form  of  sen- 
sory paralysis.     They  will  be  <lescribed  later. 

"  Hemiantesthesia  (when  not  due  to  hysteria  or  spinal  lesions)  indi- 
cates that  the  exciting  lesion  has  impaired  the  conducting  power  of  the 
fibres  associated  with  the  so-called  '  sensory  area'  of  the  cerebral  convo- 
lutions (Fig.  5).  There  is  strong  clinical  evidence  to  sustain  the  opinion 
that  these  fibres  run  in  the  posterior  third  of  the  'internal  capsule.' 
Lesions  of  this  latter  region  are  not  infrequently  the  cause  also  of  more 
or  less  impairment  of  sight,  smell,  hearing,  and  taste,  in  addition  to  their 
effects  upon  general  sensation.  Charcot,  Ferrier,  Rendu,  Raymond,  and 
others  who  have  studied  the  effects  of  lesions  of  the  posterior  third  of 
the  internal  capsule  of  the  cerebrum  concur  in  this  statement. 

"  Hemiana'sthesia  is  frequently  accompanied  by  the  development  of 
choreiform  movements  after  the  paralysis  has  developed.  These  may 
assume  the  type  of  athetosis,  true  ataxia,  or  tremor.  The  same  may 
also  be  said  of  that  type  of  hemiplegia  which  occurs  as  the  result  of 
lesions  of  the  internal  capsule  of  the  cerebrum.  Finally,  in  cerebral 
hemiantesthesia  there  is  usually  more  or  less  insensibility  to  touch,  pain, 
and  temperature,  and  also  abolition  of  muscular  sensibility  with  complete 
retention  of  electro-motor  contractility.  The  mucous  membranes  of  the 
eye,  nose,  and  mouth,  are  also  frequently  rendered  anesthetic.  Aphasic 
symptoms  have  been  observed  to  co-exist  with  hemiangesthesia  (see 
page  68)." 

NUMBNESS   AND   FORMICATION. 

In  connection  with  sensory  paralysis,  a  condition  of  numbness, 
which  the  patient  describes  as  feeling  as  if  some  special  part  was  "  fast 
asleep"  is  often  experienced.  In  othei's,  a  sensation  which  has  been  com- 
pared to  the  "  creeping  of  ants  "  over  some  special  region  is  complained 
of.     The  latter  has  been  termed  "formication." 


56  LECTURES   ON   NERVOUS   DISEASES. 

"These  jibnormul  sfiisutioiis  are  confiiu'd  cxelusivcly  to  tliose  jjtuts 
in  "which  the  sensory  nerves  are  more  or  less  impaired.  This  im|)airment 
may  result  from  some  lesion  of  the  nerves  after  their  escape  from  the 
brain  or  spinal  cord,  or  from  lesions  of  the  nerve  centres  which  involve 
their  fibres  of  oriiiin. 

"  By  a  careful  study  of  the  syniptonis,  a  skilled  anatomist  is  often 
enabled  to  decide  whether  the  lesion  is  cerebral,  spinal,  or  confined  to 
special  nerve  trunks.  This  field  is  too  extensive,  however,  to  be  consid- 
ered in  detail  here." 

HYPERESTHESIA. 

In  connection  with  lesions  of  tlie  brain  and  spinal  cord,  a  condition 
of  excessive  sensibility  is  sometimes  encountered.  It  is  termed  "  h^-per- 
sesthesia." 

"  It  may  exist  independently  of  motor  or  sensory  paralysis  ;  or.  ao:ain, 
it  ma}'  co-exist  with  them.  Its  clinical  significance  depends  upon  its  seat 
and  extent  and  the  other  evidences  of  disturbed  nervous  functions  wliieh 
co-exist.  It  will  be  discussed  from  a  clinical  point  of  view  in  subsequent 
pages."' 

HEMIANOPSIA. 

A  loss  of  vision  in  one  lateral  half  of  each  retina  is  termed  ''  hemi- 
anopsia" and  "  hemianopia."  It  is  called  "  hemiopia  "  by  some  authors  ; 
although  incorrectly  so,  as  that  term  means  "  half-vision,"  while  the  two 
others  mean  what  they  are  intended  to  express. 

The  following  steps  are  commonly  employed  to  detect  the  existence 
of  this  symptom  :  Request  the  patient  to  close  one  e^^e  by  pressing  the 
lid  down  with  the  finger,  and  to  so  direct  the  open  eye  as  to  concentrate 
its  gaze  upon  some  fixed  object  near  to  it.  [I  usually  hold  up  the  fore- 
finger of  my  own  hand  within  a  foot  of  the  i)atient's  open  eye,  and  tell 
him  to  look  steadilj-  at  it.]  Having  done  this,  take  some  object  which  is 
easily  seen  (such  as  a  piece  of  white  paper)  in  the  unemployed  hand,  and 
move  it  to  the  right  and  left  of  the  object  upon  which  the  patient  is 
gazing,  and  also  above  and  below  the  object,  asking  the  patient,  in  each 
case,  if  the  two  objects  are  seen  simultaneousl}'  and  with  distinctness, 
and  notice  upon  which  side  of  the  fixed  object  the  patient  cannot  perceive 
the  moving  object.  It  is  self-evident  that  the  retina  is  blind  upon  the 
side  opposite  to  that  upon  which  the  moving  object  is  lost  to  sight. 

The  most  common  form  of  hemianopsia  is  that  in  which  the  nasal 
half  of  one  eye  and  the  temporal  half  of  the  other  is  blind.  This  condi- 
tion is  termed  homonymous  hemianopsia.  It  is  the  result  of  pressure 
upon,  or  actual  destruction  of  one  of  the  optic  tracts,  the  pulvinar  of 
the  thalamus,  the  cortex  of  the  occipital  lobe  (probably  the  cuneus),  or 
the  fibres  that  connect  it  with  the  optic  tract.  (This  seems  to  be  proven 
by  the  late  researches  of  Munk,  Wernicke,  Starr,  Seguin,  and  others.) 


HEMIANOPSIA. 


57 


c  ■  a  ■ 


d    b 


Cortical  visual 
area  of  right 
cerebral  hemi- 
sphere. 


Fig  21  —A  Diagram  by  the  Author  Explicative  of  Hemianopsia.  The  'mes  (-4  and 
51  indicate  the  fibres  associated  with  the  left  cerebral  hemisphere.  Those  of  the  right 
hemisphere  (C  and  V)  appear  as  separate  lines.  Both  will  be  seen  ni  the  diagranr  to 
p^sTrom  the  retina  through  the  following  parts:  The  optic  nerves;  the  crossmg  fibres 
through  the  optic  chiasm;  the  optic  tracts  ;  the  external  geniculate  body  ;  the  £?^ P^J,^  3"^^- 
rigenfina  or  the  "  pulvinar"  of  the  optic  thalamus  ;  and  the  internal  capsule.  The  fibres  are 
shown  to  end  in  the  cortex  of  the  occipital  lobes.  ,    ,       .,,  ,     „         „„,,c 

A  lesion  situated  at  the  points  designated  as  1  2  3,  4,  and  5,  will  '^^"f^.»^°";^">;'?°"^ 
hemianopsia.  Lesions  of  the  rig-hi  hemisphere  of  the  cerebrum  produce  blindness  of  the 
right  halfai  each  eye,  and  vice  vey':a 


58 


LECTURES   ON   NERVOUS   DISEASES. 


Lesions  at  the  bivse  of  the  skull  freciuently  produce  this  variety  of 
hemianopsia,  if  the^'  lie  posteriorly  to  the  optic  chiasm.  In  this  situa- 
tion, the  lesion  usually  produces  the  symptoms  which  are  referable  to 
pressure  upon,  or  destruction  of  the  bundles  of  motor  or  sensory  fibres 
found  in  the  crus  and  below  it,  or  some  of  the  nerves  whicli  escape  from 
the  base  of  the.  skull.  Fig.  21  will  aid  the  reader  in  appreciating  the 
clinical  value  of  this  suggestion. 

Whenever  the  chiasm  is  affected,  we  meet  tlie  binasal  type.  Regions 
e  and  6,  in  Fig.  21,  would  then  be  deprived  of  visual  perceptions. 

There  is  still  one  more  form  of  hemianopsia  whicli  is  occasionally 
encountered,  viz.,  the  bitemporal  t3'pe.     This  has  been   interpreted  by 


VISUAL  AREA 


^''BPcs  fj 


MEDULLA 


Fig.  22. — A  Diagram  Designed  by  the  Author  to  Show  the  General  Course  of  Fibres 
OF  THE  "Sensory"  and  "Motor  Tracts,"  and  their  Relation  to  Certain  P'as- 
cicuLi  of  the  (Jptic  Nerve  Tracts.  (Modified  from  Seguin.)  S,  Sensory  tract  in  posterior 
region  of  mesocephalon,  extending  to  O  P  and  T,  occipital,  parietal,  and  temporal  lobes  of 
hemispheres;  M,  motor  tract  in  basis  cruris,  extending  to  P  and  F,  parietal  and  (part  of) 
frontal  lobes  of  hemispheres;  C  Q,  corpus  quadrigeminum;  O  T,  optic  thalamus;  N  L, 
nucleus  lenticularis;  N  C,  nucleus  caudatus;  1,  the  fibres  forming  the  "tegmentum  cruris" 
(Meynert) ;  2,  the  fibres  foiming  the  "  basis  cruris"  (Meynert);  a,  fibres  of  the  optic  nerve 
which  become  associated  with  the  "optic  centre"  in  the  optic  thalamus,  and  are  subse- 
quently prolonged  to  the  "visual  area"  of  the  occipital  convolutions  of  the  cerebrum;  b, 
optic  fibres  which  join  the  cells  of  the  "  corpora  quadrigemina,"  and  are  then  prolonged  to 
the  visual  area  of  the  cerebral  cortex. 

an  autopsy  made  upon  a  case  intrusted  to  the  care  of  Professor  H. 
Knapp,  of  this  city.  It  must  be  evident  tliat  the  chances  would,  of 
necessity,  be  extremely  small  of  ever  encountering  a  bilateral  lesion 
which  would  affect  only  those  fibres  of  tlie  optic  chiasm  or  optic  tract 
which  supply  the  temporal  half  of  each  retina,  and  at  the  same  time 
leave  the  decussating  fibres  intact.  How,  then,  are  we  to  account  for 
the  fact  that  this  form  is  sometimes  met  with  ?  I  would  call  attention 
to  a  peculiar  arrangement  of  the  arteries  in  tlie  region  of  the  optic 
chiasm  as  a  factor  in  causing  this  condition.  It  has  been  shown  that 
atheromatous  degeueration  of  the  ''circle  of  Willis"  (a  peculiar  arrange- 


HEMIANOPSIA. 


59 


meiit  of  blood-vessels  at  the  base  of  the  brain)  so  impairs  the  elasticity 
of  the  arteries  as  to  create  through  their  pulsation  a  type  of  injury  to 
the  chiasm,  so  limited  in  its  extent  as  to  impair  only  the  fibres  dis- 
tributed to  the  temporal  halves  of  the  retinae,  and  thus  to  create  bi- 
temporal hemianopsia. 

Hemianopsia  will  be  more  fully  discussed  in  connection  with  the 
effects  of  lesions  of  the  optic  nerve.  The  diagrams  introduced  will,  I 
trust,  make  the  facts  stated  clear  to  the  mind  of  the  reader. 


v_-(_^^i^      \    MEDULLA 


Fig.  23. — A  Diagram  Designed  by  the  Author  to  Show  some  of  the  Relations  of  the 
Optic  and  Olfactory  Nerve  Fibres  to  Surrounding  Parts.  F,  Frontal  lobes  of  cere- 
brum ;  P,  parietal  lobe;  T,  temporo-sphenoidal  lobe;  S,  fissure  of  Sylvius;  R,  fissure  of 
Rolando;  O,  occipital  lobe;  C,  cerebellum;  .M,  medulla  oblongata;  1,  olfactory  nerve;  2, 
optic  chiasm  ;  3,  motor-oculi  nerve;  4,  corpora  quadrigemina;  5,  trigeminus  nerve ;  a,  basis 
cruris  ;  b,  tegmentum  cruris.  The  diamonds  in  the  occipital  lobe,  the  cortical  visual  centres 
of  Munk.  The  cerebellum  and  pons  Varolii  are  shown  as  if  separated  from  the  cerebrum, 
in  order  to  made  the  relations  of  the  crus  to  the  optic  tracts  apparent.  This  diagram  should 
be  compared  with  the  preceding  ones  (Figs.  21  and  22)  to  make  its  bearings  upon  cerebral 
localization  apparent. 

We  may,  therefore,  summarize  the  clinical  significance  of  this  peculiar 
form  of  blindness  as  follows  :  (a)  The  homonymous  variety  indicates 
lesions  affecting  the  optic  tract  or  its  continuation  backward  ;  or,  possibly 
a  lesion  of  the  cortex  of  the  occipital  lobe  of  the  same  side.  (6)  The  bi- 
nasal  variety  indicates  a  lesion  pressing  upon  the  central  portion  of  the 
chiasm,  (c)  The  bitemporal  variety  indicates  atheromatous  degene- 
ration of  the  circle  of  Willis.  Symmetrical  lesions  of  the  outer  part  of 
the  chiasm  might  possibly  (?)  also  cause  it. 


60  LECTURES   ON   NEllVOUS   DISEASES. 

APHASIA. 

An  impairment  of  tlie  idea  of  language  or  its  expression  (inde- 
pendent of  paralj^sis  of  the  tongue)  constitutes  this  condition. 

It  is  commonly  described  as  of  two  varieties — the  sensory  or  ''am- 
nesic form,"  in  whifh  tlie  memory  of  words  or  of  symbols  is  more  or  less 
effaced,  and  the  motor  or  ''ataxic"  variety,  in  which  the  memory  is  per- 
fect, but  the  subject  cannot  properly  pronounce  words,  from  an  inability 
to  perfectly  coordinate  the  muscles  concerned  in  articulation. 

The  symptoms  of  this  malady  in  either  of  its  forms  are  always  of 
great  clinical  interest,  because  some  peculiarity  in  each  case  causes  it  to 
differ  from  others  which  may  have  been  previously  encountered. 

I  quote  from  the  third  edition  of  my  work  on  "  Surgical  Diagnosis," 
some  selected  paragraphs  relating  to  this  symptom,  with  occasional 
changes  in  their  phraseologv : — 

"  In  the  amnesic  varieti/  the  most  familiar  objects  are  commonly 
misnamed ;  the  subject  being  oftentimes  aware  that  the  error  has  been 
committed,  and  yet  is  not  able  to  correct  it.  The  form  which  this  loss 
of  memory  takes  is  liable  to  vary  with  each  case.  As  an  illustration  of 
this,  some  forget  only  names  ;  others  only  numbers.  In  certain  reported 
cases,  the  names  of  things  only  in  dead  or  foreign  languages  were  re- 
tained; in  others,  the  reverse  had  been  observed,  the  patient  losing  all 
memory  of  acquired  tongues.  Again,  the  sound  of  words  often  will  not 
be  recognized  when  the  letters  which  form  them  will ;  and  the  reverse  of 
this  condition  is  not  infrequently  met  with  in  aphasic  subjects. 

"  We  owe  to  Broca  the  credit  of  the  discovery  that  the  centre  for 
the  coordination  of  the  movements  of  the  tongue,  lips,  and  palate,  neces- 
sary to  articulate  speech,  could  be  located  in  the  posterior  portion  or  base 
of  the  third  frontal  convolution ;  and  to  man3'  of  the  later  pathologists 
the  debt  of  overthrowing  what  once  was  the  popular  view,  viz.,  that  this 
centre  is  not  confined  exclusively  to  the  left  cerebral  hemisphere.  Sub- 
sequent pathological  observation  seems  to  have  added  strength  to  the 
view  that  lesions  of  the  '  island  of  Reil,'  as  well  as  the  medullary  sub- 
stance which  intervenes  between  it  and  the  centre  of  Broca,  must  be  in- 
cluded in  the  so-called  'motor  speech  area.'  The  amnesic  form  may  be 
dependent  likewise  upon  lesions  of  the  so-called  'sensor}'  areas'  of  tlu- 
cortex. 

"  The  'centre  of  Broca'  is  supplied  with  blood  by  the  middle  cere- 
bral artery.  An  embolus  within  that  vessel  will  tend,  therefore,  to  arrest 
the  circulation,  of  that  important  area,  and,  at  the  same  time,  it  will  in- 
terfere more  or  less  witli  the  nutrition  of  the  motor  area  of  the  cortex 
and  the  corpus  striatum — the  ganglion  which  probably  modifies  all  motor 
impulses  sent  out  from  the  brain  to  the  muscles  of  the  opposite  side  of 


APHASIA.  61 

the  body.  Now  we  know  clinically  that  embolism  is  a  freqiient  cause 
of  aphasia,  and  tliat  lieraiplegia  almost  always  accompanies  it.  We  also 
know  that  the  middle  cerebral  artery  of  tlie  left  side  is  tlie  most  frequent 
seat  of  embolic  obstruction.  This  fact  helps  us  to  interpret  the  devel- 
opment of  right  Iiemiplegia  in  connection  with  aphasia,  as  is  found  to 
exist  in  the  large  proportion  of  such  cases.  Seguin  found  two  hundred  and 
forty -three  cases  in  which  riglit  hemiplegia  existed  out  of  a  total  of  two 
hundred  and  sixtj^ — left  hemiplegia  being  present  in  but  seventeen  cases. 

"  In  the  ataxic  variety  of  aphasia,  tlie  patient  can  usually  write  wliat 
cannot  be  spoken,  thus  proving  that  the  memory  of  words  seen  or  heard 
is  not  effaced,  but  rather  the  ability  to  so  coordinate  the  muscles  of  speech 
as  to  properly  pronounce  them.  This  condition  must  not  be  confounded 
with  aphonia  (loss  of  voice).  Several  cases  have  been  reported  where  the 
amnesic  form  has  given  place  to  the  ataxic,  and  the  lesion  has  been  found 
over  the  centre  of  Broca.  It  would  seem,  therefore,  that  the  tiiird  frontal 
convolution  (although  placed  in  close  relationship  with  tlie  oral  and 
lingual  centres  of  Ferrier)  has  some  imperfectly  understood  connection 
with  the  memory  of  words,  as  well  as  with  the  coordinated  movements 
of  the  apparatus  of  speech. 

"  If  irritative  or  destructive  lesions  of  the  cerebral  cortex  exist  as- 
the  exciting  cause  of  the  apliasia,  convulsions  ma}-  be  associated  with  its 
development. 

"If  numbness  or  anaesthesia  co-exist  with  hemiplegia  and  aphasia,  it 
indicates  that  the  'motor  and  sensory  tracts'  which  connect  the  cere^ 
brum  with  the  exti'emities  are  involved,  as  well  as  the  centre  of  speech, 
or  the  'speech  tract.'" 

We  have  reason  to  believe  that  the  cortical  cells  of  the  so-called  "  sen- 
sory area "  of  tlie  cerebrum  not  only  enable  us  to  appreciate  the  many 
i'acts  telegraphed  to  them  by  the  organs  of  smell,  sight,  hearing,  taste, 
and  touch;  but  that  each  cell  is  able  furthermore  to  store  up  such  impres- 
sions as  it  is  speciall^^  designed  to  take  cognizance  of,  and  to  recall  them 
at  the  command  of  the  will  as  memories  of  past  events. 

Munk  has  lately  demonstrated  that  the  cortical  cells  of  the  occipital 
lobes  preside  over  vision;  and  that  a  permanent  loss  of  sight  follows  the 
totiil  destruction  of  these  lobes.  The  same  observer  has  shown,  also, 
when  a  circumferential  ring  of  cells  in  the  occipital  lobes  were  not  in- 
cluded in  the  experiment  (the  central  portions  only  of  the  lobes  being 
removed),  that  an  animal  will  slowly  regain  its  familiarit}^  with  surround- 
ing objects  through  the  sense  of  sight.  A  dog,  for  example,  will  learn 
to  again  recognize  faces,  can  be  taught  anew  to  fear  the  lash,  to  i-ecognize 
food  by  sight,  etc.  The  onl^^  explanation  of  such  facts  is  that  the  new 
sight-memories  are  formed  in  place  of  those  that  were  obliterated  b}'  the 
operation. 


62  LECTURES    ON   NERVOUS   DISEASES. 

Experimental  investigation  and  j^athological  facts  lead  us  to  the 
conclusion  that  the  various  forms  of  memories  recognized  are  stored  up 
in  those  cortical  cells  which  were  originally  thrown  into  activity  by  the 
fact  remembered.  Thus,  for  example,  the  cells  of  the  area  of  hearing 
give  to  us  our  memories  of  sound ;  those  of  the  sight  area  our  memories 
of  visual  impressions;  and  those  of  the  smell  area  our  memories  of  odor. 
Some  remarlvable  clinical  facts  sustain  the  view  that  the  cells  of  the  motor 
area  even  are  capable  of  giving  to  us  memories  of  muscular  efforts.  These 
are  totally  distinct  from  other  forms  of  memory.  Professor  Charcot  lately 
reported  a  case  where  a  gentleman  could  read  by  tracing  the  lines  with 
his  finger,  when  a  lesion  of  the  brain  had  deprived  him  of  his  ability 
to  recognize  written  or  printed  characters  by  sight.  He  could  write  with 
ease,  but  could  read  what  he  had  written  only  by  retracing  the  lines,  or 
going  through  tlie  motions  necessary  to  reproduce  the  letters. 

Dr.  M.  A.  Starr  has  lately  written  two  popular  articles,*  in  which 
the  physiology  of  speech  is  discussed  at  some  length.  It  is  illustrated 
with  some  admirable  diagrams.  This  author  cites  many  interesting  cases 
which  illustrate  the  various  types  of  aphasia,  and  he  supports  the  view 
that  the  parietal  convolutions,  Avhich  are  not  related  to  muscular  move- 
ments, are  the  seat  of  our  conscious  appreciation  of  tactile  impressions 
and  of  touch-memories.  Ross,  Hughlings- Jackson,  Bastian,  Broadbent, 
Kussmaul,  and  others,  have  written  extensively  upon  this  subject. 

Much  light  has  been  shed  by  recent  investigations  upon  those  cases 
of  aphasia  where  the  ability  to  respond  to  spoken  questions  has  been 
destroyed  by  focal  lesions  of  the  brain,  and  the  patient  has  still  been 
able  to  appreciate  written  interrogations  and  to  reply  to  the  same.  Cases 
also  where  the  reverse  has  been  observed,  are  now  understood. 

The  condition  known  as  "  word-deafness  "  is  to  be  clinically  regarded 
as  a  symptom  of  a  lesion  affecting  the  superior  temporal  convolution,  in 
which  the  centres  of  hearing  are  situated.  The  condition  known  as 
'•'■word-blindness''''  indicates  a  lesion  of  the  occipital  lobes. 

The  centre  of  Broca  must,  therefore,  be  regarded  as  related  exclu- 
sively to  motor  speech  memories,  which  can  be  called  into  activity  by  the 
different  parts  of  the  cortex  in  case  any  impression  received  b}'  them 
demands  a  verbal  response. 

We  are  in  possession  of  facts  to-day  that  render  it  certain  that  the 
nuclei  of  origin  within  the  medulla  oblongata  of  the  nerves  which  preside 
over  the  tongue,  lips,  and  palate,  are  connected  with  those  cortical  cen- 
tres that  are  functionally  related  to  speech  by  the  fibres  of  the  so-called 
^'■sjieech  tract.''''  Wernicke  has  lately  traced  the  coui'se  of  these  fibres  by 
a  study  of  reported  cases  which  bear  upon  this  field.  He  places  them  in 
t\xQ  2)Osterior  part  of  the  internal  capsule  (Fig.  24),  and  states  that  they 
*  Poptdar  Science  Monthly,  Sept.,  1884;  Princeton  Review,  May,  1886. 


PARAPHASIA — TRUE   MOTOR   APHASIA.  63 

pass  also  through  the  external  capsule  to  reach  the  third  frontal  convo- 
lution. This  discovery  enables  us  to  explain  the  co-existence  of  aphasia 
with  hemiantesthesia  and  hemianopsia,  which  has  beeii  observed.  It  also 
clears  up  those  cases  where  lesions  of  the  crus,  pons,  and  medulla  have 
produced  aphasic  s^^raptoms.  The  "  speech  tract "  must  not  be  con- 
founded wnth  the  cerebral  extension  of  fibres  of  the  hypoglossal  nerve, 
which  have  a  different  course. 

Clinically,  we  may  be  called  upon  to  recognize  the  following  varie- 
ties of  defective  speech  produced  by  brain  lesions : — ■ 


(1)  Motor  or  "Ataxic"  Aphasia. 

(2)  Sensory  or  "  Amnesic  "  Aphasia  . 


Paraphasia. 
Word-deafness. 
Word-blindness. 
Agraphia. 


PARAPHASIA. 


This  is  a  condition  where  the  substitution  of  wrong  words  or  syvihols 
occurs  in  conversation  or  during  attempts  at  writing.  The  patient  is 
conscious  of  this  error,  but  is  unable  to  correct  it.  Nouns  are  more 
frequentl}'  lost  than  verbs.  Patients  of  this  type  often  exercise  great 
ingenuity  in  avoiding,  during  conversation  or  writing,  the  words  which 
they  are  liable  to  fail  in  properly  recalling.  By  means  of  oddly-con- 
structed sentences  they  will  often  hide  this  defect  in  speech  from 
strangers.  A  good  test  often  for  such  cases  is  to  request  the  patient 
to  say  his  alphabet,  and  to  count  until  requested  to  cease.  These  pa- 
tients will  probably  substitute  wrong  letters  or  figures  for  the  proper 
ones. 

Paraphasia  is  due  to  a  lesion  of  the  island  of  Reil.  On  the  left  side 
of  the  brain  in  right-handed  subjects,  or  vice  versa. 

TRUE   MOTOR   APHASIA. 

This  condition  is  due  to  a  lesion  in  the  centre  of  Broca  (third 
frontal  convolution). 

These  patients  cannot  articulate  correctly.  They  are  painfully  con- 
scious of  this  defect ;  hence  they  frequently  become  mute  rather  tlian 
to  expose  themselves  to  criticism  or  ridicule.  I  have  known  such 
patients  to  be  deemed  a  melancholiac  because  they  could  not  be  induced 
to  tallv. 

In  case  certain  words  are  retained  or  regained  after  the  attack,  these 
words  or  expressions  are  used  in  a  peculiarly  automatic  way  by  the 
patient  in  reply  to  any  question  asked.  It  is  not  uncommon  for  a 
patient  with  motor  aphasia  to  use  some  absurdh'  irrelevant  phrase  as  an 
answer  to  any  question  which  may  be  propounded.  Occasionalh",  this 
phrase  maj^  be  traced  to  some  peculiar  expression  which  existed  in  the 


64  LECTURES   ON  NERVOUS   DISEASES. 

mind  of  the  patient  at  the  time  when  the  attaclc  occurred.  As  examples, 
a  case  is  reported  by  Hammond  wliore  a  patient  wouhl  reply  "  hell  to 
pay"  under  all  circumstances;  and  another  by  Hughlings-Jackson  where 
the  unvarying  reply  was,  "  1  want  protection." 

AGRAPHIA. 

This  term  is  applied  to  a  condition  where,  from  cerebral  disease  or 
other  causes,  the  power  of  writing  is  suddenly  or  gradually  lost. 

The  explanation  of  this  condition  rests  in  the  fact  that  the  patient 
has  lost  certain  memories  which  previously  enabled  him  to  make  the 
necessary  finger  movements  for  placing  upon  paper  results  obtained  by 
his  mental  processes. 

Such  a  person  might  be  able  to  perform  any  or  all  movements  of 
the  fingers  (that  are  not  connected  with  the  writing  of  letters  or  figures) 
with  his  accustomed  delicacy.  He  cannot  write  from  dictation,  or  copy 
from  a  printed  or  written  slip.  He  is  not  paralyzed,  nor  is  he  affected 
with  "  writers'  cramp."  The  memory  is  alone  at  fault;  hence  this  con- 
dition is  a  variety  of  "amnesic  aphasia." 

In  some  instances,  delicate  finger  movements  required  in  the  me- 
chanical trades,  the  use  of  musical  instruments,  etc.,  have  been  known  to 
be  suddenly  taken  away  from  a  similar  loss  of  motor-memories.  Such 
cases  are  not  included  under  the  term  "agraphia." 

WORD-DEAFNESS. 

This  is  a  form  of  sensory  aphasia  which  is  due  to  a  lesion  of  the  first 
temporal  convolution.  These  patients  cannot  be  made  to  understand 
.spoken  language,  because  their  centres  of  hearing  have  been  impaired. 
They  are  not  deaf  to  sound,  but  they  fail  to  appreciate  the  meaning  of 
certain  sounds.  Their  own  tongue  is  as  unintelligible  to  them  as  a 
foreign  language. 

This  condition  prevents  the  patient  from  speaking  correctly,  because 
of  an  inability  on  his  part  to  recall  the  proper  sound  of  many  words  pre- 
viously employed  by  him.  Their  efforts  to  talk  or  to  read  aloud,  result 
in  an  "  unintelligible  jargon  "  which  the  patient  does  not  recognize  as  in 
any  respect  unnatural  or  inexpressive  of  ideas  he  desires  to  commu- 
nicate to  you,  because  his  ear  does  not  properly  interpret  his  own 
utterances. 

You  may  test  such  a  patient,  therefore,  by  asking  him  to  read  aloud 
some  printed  selection,  or  to  write  at  your  dictation.  With  neither  of 
these  tests  will  he  be  able  to  fully  comply. 

Starr  quotes  from  Broadbent  the  following  illustrative  case; — 

"One  such  person  was  asked  to  read  the  sentence,  'You  may  receive 
a  report  from  other  sources  of  a  supposed  attack  on  a  British  consul- 


WORD-BLINDNESS.  65 

oeneral.  The  affaii*  is,  however,  unworthy  ot"  consideration/  He  read  it 
slowly,  and  in  a  jerky  manner,  as  nearly  as  could  be  taken  down,  thus: 
'  So  sur  wisjee  coz  wenenient  apripsy  fro  freuz  fenement  wiz  a  seconce 
coz  foz  no  Sophias  a  the  freckled  i)othy  conollied.  This  aliair  eh  oh 
cont  oh  curly  of  consequences.'  It  was  evidently  an  effort  to  read  aloud, 
requiring  close  attention,  and  he  read  seriously  and  steadily,  apparently 
unconscious  of  the  absurdity'  of  his  utterances,  till  interrupted  by 
laughter,  which  it  was  impossible  to  restrain.  He  was  never  able  to 
write  at  dictation,  but  he  signed  his  name  quite  well,  and  could  copy 
accurately,  though  as  he  wrote  each  letter  he  would  attempt  to  name  it 
aloud,  but  always  pronounced  a  wrong  letter." 

WORD-BLINDNESS. 

This  is  another  form  of  sensory  aphasia.  It  is  due  to  a  lesion  of 
the  visual  centres  in  the  occipital  lobes.  It  is  accompanied  by  a  loss  of 
memory  of  the  meaning  of  printed  or  written  symbols.  Such  patients  can 
generally  recognize  familiar  objects  or  faces,  but  they  cannot  read  cor- 
rectly. 

When  asked  to  read  a  printed  selection  or  a  written  slip,  their  inter- 
pretation is  an  incorrect  one  The}^  can  often  write  from  dictation,  but 
they  cannot  read  what  they  have  written.  Their  conversational  powers 
are  not  impaired  unless  "  word-deafness  "  is  also  present. 

The  following  illustrative  case  is  quoted  by  Starr,  from  a  contri- 
bution of  Ross  upon  this  condition : — 

"  One  man  who  had  suffered  from  this  affection  seemed  at  first  un- 
conscious of  his  actual  condition.  When  asked  to  read  he  would  make 
very  elaborate  preparations,  putting  on  his  spectacles  and  moving  the 
paper  or  book  backward  and  forward  until  he  seemed  to  get  it  into  a 
position  where  he  could  see  well.  He  would  then  read  aloud,  uttering  a 
few  sentences  which  had  not  the  remotest  connection  with  anything  that 
was  before  him  on  the  printed  page.  He  was  handed  a  note  which  read 
as  follows:  'Dear  Sir,  I  shall  be  much  obliged  if  you  will  let  me  know 
whether  or  not  you  consider  it  likely  that  A.  B.  will  recover.'  He  looked 
at  it  carefully,  and  seemed  to  glance  it  through,  and  then  read  slowly 
and  deliberately,  and  without  much  hesitation :  '  Dear  Sir,  You  ai-e  re- 
quested to  bring  this  note  with  you  the  next  time  you  come  to  the  in- 
firmary;' and  then  he  added,  'that  is  what  I  make  of  it;  I  don't  know 
whether  it  is  right  or  not.'  He  often  tried  to  read  a  newspaper  aloud, 
and  his  wife  said  that  he  '  read  a  lot  of  stuff'  all  made  up  out  of  his  own 
head.'  On  one  occasion  she  took  the  paper  and  read  it  to  hiin.  He  was 
very  quiet  for  a  time,  and  then  asked, '  Is  that  what  it  says  in  that  pa^jer?' 
and  when  she  assured  him  that  it  was,  he  said,  'Well,  then,  I  must  be  an 
idiot.'     At  that  time  he  would  remark,  '  I  don't  know  what  is  the  matter 


66  LECTURES   ON   NERVOUS   DISEASES. 

with  the  newspapers  nowadaj's,  they  are  filled  with  such  silly  stuff.' 
Soon,  liowever,  he  began  to  realize  that  the  trouble  lay  in  himself  rather 
than  in  the  papers,  and  then  he  gave  up  attempting  to  read." 

It  is  not  uncommon  to  encounter  this  form  of  aphasia  in  conjunction 
with  word-deafness,  a  fixct  which  is  easily  explained  b^-  the  close  ])rox- 
imity  of  the  visual  and  auditory  centres  (see  Fig.  5). 

GENERAL   DEDUCTIONS   RELATIVE   TO   APHASIA. 

In  summary,  the  following  deductions  relative  to  disorders  of  speech 
may  be  given  : — 

1.  The  cortex  of  the  posteinor  part  of  the  third  frontal  convolution^ 
and  possibly  the  island  of  Reil  also,  presides  over  the  coordination  of  such 
muscular  acts  as  are  necessary  to  speech.  It  also  stores  the  memories  of 
such  acts,  so  that  any  combination  of  articulate  sounds  can  be  voluntaril}' 
reproduced  when  the  proper  form  of  excitation  is  furnished  (chiefly  in 
response  to  sight  or  sound-impressions). 

This  centre  is  connected  b^-  "  associating  fibres  "  with  the  centres  of 
hearing  (first  temporal  convolution)  and  those  of  sight  (the  occixjital  con- 
volutions). It  is  also  put  in  communication  with  the  nuclei  of  the  facial, 
hypoglossal,  pneumogastric,  and  glosso-pharyngeal  nerves  (within  the 
medulla)  b}'  means  of  two  distinct  tracts  of  fibres,  viz.,  the  "  hA'pogiossal 
cerebral  tract,"  and  the  so-called  "speech  tract." 

Thus,  this  cortical  centre  of  coordinated  speech-movements  is  ca- 
pable of  receiving  excitation  from  the  centres  of  hearing,  when  replies 
to  spoken  language  are  demanded;  and  from  the  centres  of  sight,  when 
written  or  printed  language  calls  for  a  verbal  response.  It  is  also  put  in 
direct  communication  with  the  nerves  which  preside  over  the  apparatus 
of  speech  (whose  nuclei  of  origin  are  situated  within  the  medulla). 

2.  The  form  of  amnesic  aphasia,  known  as  ^'  icord-deafness''^  (Kuss- 
maul)  indicates  the  existence  of  a  lesion  of  the  first  temporal  convolu- 
tion* of  the  left  side,  which  has  impaired  the  memories  of  spoken  lan- 
guage. Hearing  may  not  be  impaired,  in  spite  of  the  fact  that  the  ajjpre- 
ciation  of  words,  music,  etc.,  may  be  totally  absent. 

3.  The  condition  known  as  ''word-blindness^'  (Kussmaul)  indicates 
the  existence  of  a  lesion  of  the  left  occipital  convolutions,  which  has  im- 
paired the  memories  of  written  or  printed  sj'mbols  of  language,  numerals, 
familiar  objects,  etc. 

4.  The  condition  termed  "  jyaraphasia'''  b}'  Kussmaul  (in  which  the 
amnesic  and  ataxic  varieties  of  aphasia  seem  to  be  peculiarly  combined) 
ma}-  be  excited  by  a  lesion  which  interferes  with  the  action  of  the  asso- 

*  In  right-handed  subjects  the  left  hemisphere,  and  in  left-handed  subjects  the  right 
hemisphere,  seems  to  monopolize  the  function  of  sound-interpretation  to  the  speech  centre. 


GENERAL   DEDUCTIONS   RELATIVE   TO    APHASIA. 


67 


ciating  tracts  of  fibres  between  the  areas  of  hearing  or  sight  and  the 
motor  speech  centre  of  Broca  (Wernicke). 

5.  The  condition  of  imperfect  speech,  termed  "  anarthria,''^  is  pro- 
duced by  a  lesion  of  the  medulla,  which  interferes  with  the  functions  of 
the  nuclei  of  the  cranial  nerves  associated  with  speech.  It  is  occasionally 
observed  in  connection  with  focal  lesions  of  the  floor  of  the  fourth  ven- 
tricle. These  cases  are  to  be  differentiated  from  aphasia  of  cortical  origin 
by  the  co-existence  of  other  symptoms  produced  by  the  medullary  lesion 
(see  sul)sequent  page). 

6.  In  order  to  properly  pronounce  any  word,  it  is  essential  that 
both  the  cortical  centre  of  speech,  and  also  the  nuclei  of  the  medulla, 
which  are  associated  with  it,  must  be  called  into  action. 


/^(^^mr/JES  OF 
^~^~^^  SIGHT 


TH£  SO-CALLED \ 

'BPSEDll  TRACT" 


JVUCLEI  OF  ORIGIN 

OF  NBBVKS 

'mPLOYED  JN  SPEECH 


Fig.  24. — A  Diagram  Designed  by  the  Author  to  Illustrate  the  Mechanism  of  the 
Apparatus  Required  in  Speech. — The  reader  must  not  regard  this  diagram  as  intended 
to  accurately  portray  the  anatomical  relations  of  the  various  centres  and  tracts  to  each  other. 

7.  The  peculiar  course  which  the  fibres  of  the  "  speech  tracV  take 
within  the  cerebral  hemisphere,  sheds  light  upon  those  reported  cases  of 
aphasia  where  the  lesion  was  situated  posterior  to  the  centre  of  Broca, 
These  fibres  run  from  the  third  frontal  gyrus  close  to  the  surface  of  the 
hemisphere,  and  in  an  antero-posterior  direction  (passing  in  the  external 
capsule)  to  reach  the  posterior  part  of  the  lenticular  nucleus.  They  dip 
at  this  point  into  the  posterior  part  of  the  internal  capsule.  They  then 
pass  through  the  middle    part  of  the  crus  and    pons   to  the   medulla 


6H  LECTURES   ON   NERVOUS   DISEASES. 

(Wernicke).  Within  the  internal  capsuh',  the  :H)res  of  the  'speech- 
tract"  lie  (according  to  this  observer)  between  the  optic  fibres  and 
those  of  the  sensory  tract. 

8.  Should  aphasia  be  developed,  as  a  result  of  a  leaion  of  (he  in- 
ternal capsule,  hemianopsia,  or  heiniaujesthesia,  would  bo  liable  to  co- 
exist, on  account  of  the  relationship  of  the  optic  and  sensory  fibres  of  the 
capsule  to  the  speech  tract. 

9.  It  is  possible  to  have  aphasic  symptoms  develop  as  a  result  of  a 
lesion  ivithin  the  eras  or  pons.  This  is  because  the  speech  tract  passes 
through  them  to  reach  the  medulla. 

10.  The  cortical  centres  of  hearing,  smell,  a3id  taste,  are  probably 
associated  (wholly  or  in  part)  with  the  corresponding  organ  of  the  oppo- 
site side.  Hence,  we  may  clinically  refer  an  abolition  of  the  function  of 
hearing  (in  case  it  be  due  to  a  cortical  lesion)  to  the  hemisphere  opposed 
to  the  deaf  ear.  ''  Word-deafness"  ma}'  ensue,  liowever,  when  the  centres 
of  hearing  of  only  one  cerebral  hemisphere  are  involved.  In  right-handed 
subjects,  the  left  superior  temporal  convolution  appears  to  govern  this 
function;  while,  in  left-handed  subjects,  the  right  superior  temporal  con- 
volution assumes  it.  This  is  probably  due  to  the  fact  that  the  hemi- 
sphere which  is  the  most  exercised,  becomes  more  rapidly  developed. 

11.  When  the  third  frontal  convolution  is  alone  diseased,  the  patient 
w^ill  l)e  able  to  understand  spoken  or  written  questions  perfectly,  but 
will  not  be  able  to  properl}'  regulate  the  movements  of  the  speech  ai)pa- 
ratus  that  are  requisite  to  a  reply. 

12.  When  the  superior  temporal  convolution  is  alone  diseased,  the 
patient  cannot  recognize  or  properly  interpret  spoken  language.  He 
ma}',  however,  be  able  to  repeat  single  words  when  propounded,  but  not 
sentences.  Exclamations  of  various  kinds  ma}'  be  uttered  by  these  sub- 
jects when  irritated  or  distressed  ;  but  they  are  more  or  less  involuntary, 
and  often  irrelevant.  The  efforts  of  these  patients  to  talk  or  read  aloud 
are  peculiarly  unintelligible. 

13.  When  the  associating  fibres  between  the  centre  of  hearing  and 
the  centre  of  Broca  are  alone  diseased,  the  patient  can  comprehend 
written  or  spoken  language  perfectly ;  but,  in  talking,  such  a  subject  is 
apt  to  interpolate,  from  time  to  time,  some  irrelevant  and  unexpected 
word  in  a  sentence  in  place  of  the  one  desired.  The  eflects  of  destruction 
of  the  associating  tracts  of  the  cerebrum  will  be  discussed  later. 

A   SUMMARY   OF   THE   DIAGNOSTIC    SYMPTOMS   BY  WHICH   LESIONS 
OF   THE   BRAIN   MAY   BE   LOCALIZED   DURING   LIFE. 
The  contents  of  the  preceding  pages  will  probably  enable  the  reader 
to  appreciate  the  grounds  which  justify  the   following  conclusions  re- 
specting the  diagnosis  of  focal  brain  lesions. 


CORTICAL   LESIONS   OF   THE   CEREBRUM.  69 

Frequent  references  will  be  made  in  subsequent  sections  of  tliis 
volume,  to  these  clinical  deductions  ;  hence  the  importance  of  a  thorough 
mastery  of  the  closing  pages  of  this  section  cannot  be  too  strongly  im- 
pressed upon  the  reader. 

CORTICAL   LESIONS   OF   THE   CEREBRUM. 

Lesions  of  the  motor  convolutions,  when  of  small  size,  produce  some 
form  of  monoplegia^  or  mono-anaesthesia;  when  of  large  size,  a  hemi- 
pler/ia  may  be  produced. 

Consciousness  is  not  necessarily  lost  at  the  time  of  the  attack.  As  a 
rule,  the  patient  is  not  rendered  totally  unconscious. 

Early  rigidity  of  the  paralyzed  muscles  is  often  present.  This  is 
]M-obably  due  to  irritation  of  the  cortex. 

Cortical  hemiansesfhesia  Avill  be  produced  when  the  entire  parietal 
cortex  is  involved  by  a  cortical  lesion,  and,  in  addition,  the  balance  also 
of  the  motor  area,  which  lies  outside  of  the  parietal  lobe.  Such  an  ex- 
tensive cortical  lesion  is  rarely,  if  ever,  encountered.  We,  therefore,  do 
not  observe  co-existing  hemiplegia  and  complete  hemiansesthesia  in  cor- 
tical disease.* 

Localized  pain  in  the  head  is  a  symptom  which  is  often  present  in 
connection  with  cortical  lesions.  If  it  be  absent,  percussion  over  the 
lesion  will  generally  tend  to  excite.  This  step  will  also  tend  to  increase 
the  pain,  in  many  cases,  where  it  exists  prior  to  this  test. 

*  The  experiments  of  Munk,  made  with  a  view  of  determining  the  area  of  common  sen- 
sation in  the  cerebral  cortex,  lead  to  the  conclusion  that  the  entire  parietal  cortex  must  be 
destroyed,  and  the  ascending  frontal  convolution  as  well,  before  complete  and  permanent  an- 
aesthesia is  produced  on  the  opposite  side  of  the  body  below  the  head.  These  results  make 
the  motor  area  overlap  the  sensory  area  to  some  extent,  and  tend  to  refute  the  deductions 
of  Ferrier,  who  places  the  centre  of  tactile  sensations  in  the  temporal  lobe,  and  to  confirm 
the  views  held  by  Luciani  and  Exner.  If  a  partial  destruction  of  the  sensory  area  of  Munk 
be  produced  in  animals,  the  anaesthesia  persists  only  for  a  few  weeks,  because  the  adjacent 
regions  learn  to  perform  vicariously  the  functions  of  the  part  destroj-ed. 

Tripier,  of  Montpellier,  France,  has  lately  affirmed  the  conclusions  of  Munk,  respect- 
ing the  existence  of  sensory  centres  in  the  central  convolutions,  as  has,  also,  Moeli,  of 
Berlin.  These  three  observers  support  the  view  that  the  motor  and  sensory  centres  of  any 
one  limb  coincide.     This  view  was  advanced  theoretically  by  Luys  some  years  ago. 

Exner  has  collected  from  European  journals  all  cases  of  cortical  disease  that  have 
been  associated  with  disturbances  of  sensation,  and  M.  Allen  Starr  has  lately  performed 
the  same  labor  in  American  literature.  An  analysis  of  the  cases  so  collected  seems  to 
justify  the  conclusions  of  Munk  and  his  followers,  and  to  add  some  clinical  suggestions  of 
value.  These  cases  demonstrate  (1)  that  the  cerebral  cortex  of  each  hemisphere  appreci- 
ates xensory  impressions  from  both  sides  of  the  body,  but  are  chiefly  associated  with  the 
sensory  tracts  of  the  opposite  lateral  half  of  the  body  ;  (2)  that  the  sensory  area  includes 
tlie  central  convolutions  (Fig.  4)  and  the  posterior  part  of  the  parietal  lobe ;  (3)  that  the 
sensory  centres  coincide  to  some  extent  with  the  motor  centres  of  similar  parts  ;  (4)  that 
no  disturbances  of  general  sensation  have  been  known  to  result  fi'om  lesions  confined  to 
the  frontal,  temporo-sphenoidal,  or  occipital  lobes. 


70  LECTUKES   ON   NEEVOUS   DISEASES. 

Convulsions,  when  followed  by  transient  attacks  of  paralysis  (Jack, 
sonian  opileps}'),  indicate  an  irritatiA-e  lesion  of  the  cortex.  The}^  are 
frequently  encountered  in  connection  with  syphilitic  disease  of  the  brain. 
Subjective  sensations  (parsesthesiae)  may  also  be  excited  in  limited  por- 
tions of  the  limbs. 

Blindness  of  that  half  of  each  retina,  which  corresponds  to  the  cere- 
bral hemisphere  affected,  occurs  when  extensive  cortical  disease  of  the 
cuneus  in  the  occipital  lobe  is  present.  '■'■  Word-blindness''''  ma}'  also  be 
produced  by  lesions  of  these  lobes  (especially  if  upon  the  left  side). 

Abolition  of  hearing,  and  also  the  condition  known  as  "  word-deaf- 
ness^^ occur  from  lesions  of  the  first  temporal  convolution  (chiefly  upon 
the  left  side). 

Abolition  of  the  sense  of  smell,  or  of  taste,  may  result  from  lesions  of 
the  tip  of  the  temporal  lobe.  The  memories  of  taste-and-smell-percep- 
tions  may  also  be  impaired  or  lost. 

Ataxic  a2:)hasia  and  paraphasia  may  be  developed  as  a  result  of  cor- 
tical lesions,  which  involve  respectively  the  speech  centre  of  Broca  and 
the  island  of  Reil. 

The  face  is  never  rendered  totally  hemiplegic  by  cortical  lesions; 
as  far  as  my  clinical  observation  and  research  among  reported  cases  goes 
to  show. 

The  conditions  known  as  "  mono-ansesthesia,^^  by  wliich  we  mean  an 
impairment,  or  total  arrest  of  sensation  in  some  distinctly  localized  part, 
as,  for  example,  the  hand,  arm,  leg,  etc.,  and,  also,  the  condition  known 
as  "  mono-par sesthesia,''''  which  signifies  the  existence  of  subjective  sensa- 
tions of  a  definitely  localized  character,  are  particularly  diagnostic  of 
cortical  lesions  lying  posterior  to  the  fissure  of  Rolando.  The  former 
indicates  a  destructive  lesion,  the  latter  an  irritative  lesion. 

The  muscular  sense  is  liable  to  be  impaii'ed  (when  a  cortical  lesion 
of  the  motor  area  exists)  in  the  parts  functionally  associated  with  the 
limits  of  the  part  diseased. 

Monoplegia  and  monosjjasm  are  pecularly  diagnostic  of  a  cortical 
disease  anterior  to  the  fissure  of  Rolando. 

Tlie  memories  of  sensory  imjjressions  are  more  frequently  impaired 
b}'  cortical  lesions  of  the  left  hemisphere  than  of  the  right  (as  shown,  for 
example,  in  ataxic  aphasia,  word-blindness,  word-deafness,  paraphasia, 
etc). 

Motor  memories  may  be  impaired  b}'  cortical  disease  afiecting  the 
motor  area.  Subjects  may  thus  lose  a  dexterity  with  the  fingers,  arm, 
hand,  leg,  etc.,  which  they  had  acquired  previous  to  the  development  of 
the  lesion.  A  knowledge  of  this  fact  may  sometimes  aitl  in  tlie  locali- 
zation of  a  lesion. 

Irritative  lesions  of  the  cortex  of  the  cuneus  (a  part  of  the  occipital 


CORTICAL   LESIONS   OF   THE   CEREBRUM. 


71 


lobes)  may  cause  hallucinations  of  vision.  If  one  hemisphere  only  is 
affected,  the  objects  seen  will  appear  to  lie  on  the  side  opposed  to  the 
lesion,  and  to  move  with  the  eyes  as  they  are  turned  from  side  to  side. 

Lesions  of  the  "  island  of  Reil,^''  or  "  insula^''  of  the  left  side  (Fig.  9), 
seem  to  create  (in  some  instances)  symptoms  of  ataxic  aphasia.,  and  also 
paraphasia  (the  substitution  of  wrong  words).  The  motility  of  the  face 
and  arm  of  the  opposed  side  may  occasionally  be  impaired  from  cortical 
lesions  of  this  region. 

Lesions  of  the  cortex  confined  to  the  apex  of  the  femjMval  lobe  (Fig. 
3)  are  liable  to  cause  an  impairment  of  the  sense  of  smell  or  of  taste  (if 
destructive  in  character);  or  subjective  odors  and  tastes  (if  irritative  in 
character). 


MEDULLA 


Fig.  25. — A  Diagram  Designed  to  Illustrate  the  General  Course  and  Distribution 
OF  the  Motor  and  Sensory  Tracts  of  the  Cerebrum.  (Modified slightly  from  Seguin.) 
P,  Parietal  lobes,  F,  frontal  lobes,  T,  temporal  lobes;  O,  occipital  lobes  ;  M,  motor  bundles  . 
S,  sensory  bundles,  N  C,  nucleus  caudatus,  N  L,  nucleus  lenticularis  ;  O  T,  oplic  thala- 
mus ,  C  Q,  corpora  quadrigemina  ,  1,  sensory  (posterior)  bundles  of  the  medulla,  pons,  and 
crus  ,  2,  motor  (anterior)  bundles  of  the  same.  Note  that  the  motor  fibres  are  associated  with 
the  frontal  and  parietal  lobes;  and  the  sensory  fibres  with  the  parietal,  temporal,  and  oc- 
cipital lobes 

Destructive  lesions  of  the  cortex  of  the  motor  convolutions  (Fig.  5) 
are  followed  b}'-  a  descending  degeneration  of  the  fibres  which  arise  from 
these  gyri.  This  may  account  (?)  for  the  late  rigidity  of  the  muscles 
paralyzed,  which  is  occasionally  observed  after  such  lesions. 

Cortical  lesions  of  the  base  of  the  brain  are  especially  liable  to  pro- 
duce vomiting,  choked  disc,  bilateral  paralysis,  and  symptoms  of  impair- 


72  LECTURES  ON  NERVOUS  DISEASES. 

ment  of  some  of  tlic  cT:ini:il  nerve  trunks.  Tlie  cms,  pons,  and  island  of 
Reil  may  also  be  involved  and  ijive  additional  symptoms. 

Cortical  disease  of  those  frontal  gyri  which  lie  anteriorly  to  the 
motor  centres  (Fig.  5)  is  often  attended  with  no  marked  symptoms  of  n 
diagnostic  character.  The  higher  mental  faculties  ma}'  occasionally  give 
signs  of  more  or  less  impairment.  Connected  thought,  the  control  of 
the  emotions,  accurate  reasoning,  and  concentration  of  the  attention  aic 
particularly  difficult  under  snch  circumstances. 

Tlie  memories  of  sound-  or  sight-impressions,  as  well  as  those  of 
smell,  taste,  muscular  movements,  etc.,  maj-  be  separately  annihilated  by 
cortical  disease  (see  Fig.  5). 

NON-CORTICAL  LESIONS   OF  THE   CEREBRUM. 

Manj'  of  the  clinical  facts  pertaining  to  non-cortical  cerebral  lesions 
may  be  thus  summarized  : — 

Profound  coma  is  more  often  encountered  in  non-cortical  lesions 
than  in  cortical;  possibly  because  the  cerebro-spinal  fluid  is  more  liable 
to  be  displaced  from  the  ventricles  (Duret). 

Hemiplegia  commonly  exists  in  combination  xoith  more  or  less  hemi- 
anaesfhesia,  and  paresis  of  the  loiver  part  of  the  face.  These  symptoms 
are  observed,  as  a  rule,  upon  the  side  of  the  bod^^  opposed  to  the  cere- 
bral lesion. 

Pain.,  when  present  in  the  head,  is  less  circumscribed  than  in  cor- 
tical disease ;  and  is  not  increased  b}-  percussion ;  or,  when  absent,  elicited 
by  that  step. 

lluscular  rigidity  in  the  paralyzed  muscles  develops  late.  Tj'pical 
'monoplegia  is  probably  never  observed. 

Tremor,  hemichorea,  and  athetosis  are  not  uncommon  sequelae  of 
non-cortical  cerebral  lesions. 

The  senses  of  sight,  smell,  hearing,  and  tactile  sensibility  are  occa- 
sionally impaired  to  a  greater  or  less  extent  by  non-cortical  lesions.  The 
seat  of  the  lesion  will  modify  the  evidences  of  such  impairment,  because 
the  fibres  of  some  of  the  cranial  nerves  may  be  involved  by  the  lesion, 
while  others  may  escape  injury, 

Tj-pical  attacks  of  Jacksonian  epilepsy  do  not  occur ;  although  gen- 
eral convulsions  may  be  excited. 

LESIONS   OF   THE    EXTERNAL   CAPSULE. 

These  may  cause  (if  within  the  left  cerebral  hemisphere)  the  con- 
dition of  p)araphasia,  which  has  been  previously  described.  This  is  due 
to  the  fact  that  the  "  speech  tract"  ])robably  passes  through  it  before  it 
enters  the  internal  capsule 


LESIONS  OF  THE  INTERNAL  CAPSULE,  ETC.         73 

LESIONS  OF  THE  INTERNAL  CAPSULE. 

These  often  result  in  the  development  of  hemiplegia,  hemianes- 
thesia, or  a  combination  of  the  two.  Hemiparalysis  of  the  lower  half  of 
the  face  may  be  produced.  The  nerve  fibres  of  sight,  hearing,  and  smell, 
and  the  so-called  "  speech  tract "  may  be  implicated.  Conjugate  deviation 
of  the  head  and  eyes  is  not  infrequent.  ''Choked  disc"  may  accompany 
this  condition,  because  it  is  a  clinical  evidence  of  an  excess  of  intra- 
cranial pressure.  The  ditferent  forms  of  tremor  already  mentioned  are 
most  common  when  the  internal  capsule  is  implicated.  Paraphasia  may 
be  induced,  if  the  "  speech  tract''  is  involved, 

LESIONS  OF  THE  CAUDATE  NUCLEUS. 

These  are  seldom,  if  ever,  associated  with  hemiansesthesia.  Hemi- 
plegia, if  developed,  is  probably  due  to  pressure  upon  the  motor  fibres 
of  the  internal  capsule.  The  face  may  develop  paralysis  in  its  lower  part 
upon  the  opposed  side  for  the  same  reason. 

Many  of  the  symptoms  enumerated  above  (as  indicative  of  a  cap- 
sular lesion)  may  exist  also  when  the  caudate  nucleus,  the  lenticular 
nucleus,  or  the  thalamus,  are  individually  attacked  by  any  lesion  which 
markedly  increases  their  size,  and  thus  creates  pressure  upon  the  fibres 
of  the  internal  capsule  (see  page  22). 

LESIONS   OF   THE   LENTICULAR   NUCLEUS. 

These  chiefly  affect  motilit}'.  Hemianaesthesia  may  occur  if  the  pos- 
terior capsular  fibres  be  pressed  upon. 

Hallucinations  are  very  common  in  connection  with  disease  of  the 
thalamus  (Ritti).  The  senses  of  sight,  hearing,  smell,  and  tactile  sensi- 
bility are  perhaps  more  liable  to  be  affected  than  motility. 

LESIONS   OF   THE   CRUS   CEREBRI. 

The  s^'mptoms  which  point  to  a  lesion  of  the  cms  (Fig.  11)  may  be 
summarized  as  follows  : — 

Grossed  paralysis  of  the  "third  nerve  and  bod\'  t^pe"  never  occurs 
except  from  a  lesion  of  the  crus. 

If  the  lesion  be  confined  to  the  tegmentum  cruris  (the  sensory  por- 
tion), hemianaesthesia  of  the  opposite  side  will  ensue,  and  the  third  and 
fifth  cranial  nerves  of  the  same  side  vnixy  possibly  be  paral3'zed.  Inco- 
ordination may  be  developed;  provided  that  the  fillet  (lemniscus)  is  in- 
volved. 

If  the  crusta  cruris  (the  motor  portion)  be  alone  involved,  paralysis 
of  the  third  nerve  will  generally  co-exist  with  hemiplegia  on  the  opposed 
side.  The  lower  part  of  the  face  may  be  rendered  jmretic,  in  some  in- 
stances, showing  that  filaments  of  origin  of  the  facial  nerve  are  impaired. 


74 


LECTURES   ON   NERVOUS   DISEASES. 


Symptoms  retcnible  to  lesions  of  the  corpora  quadrigemina  may 
be  developed  in  connection  ivith  lesions  of  llie  tegmentum  cruris  (Fig. 
11).  Among  these,  the  following  may  be  prominently  mentioned:  Inco- 
ordination of  movement ;  abolition  of  the  pnpillary  reflex ;  nystagmus ; 
and  strabismus.  Blindness  may  be  found  to  exist  independent  of  the 
presence  of  a  choked  disc,  atrophy  of  the  optic  nerve,  or  an  optic  neu- 
ritis. 


_    <  Line  of  Gubler. 


MEDUUA 


Fig.  26. — A  Diagram  op  the  Base  of  the  Brain,  Designed  to  Show  the  Parts  Ad- 
jacent TO  THE  Optic  Nerve  Tracts  and  Chiasm. — The  nerves  are  represented  by 
their  respective  numbers.  II.,  optic;  III.,  motor  oculi ;  IV.,  trochlearis ;  V.,  trigeminus, 
VI.,  abducens  ;  C,  crus  cerebri  of  each  hemisphere;  b,  infundibulum,  the  pituitary  body 
being  cut  off  to  show  the  optic  chiasm  ;  a,  the  corpus  albicans  (mamillary  tubercle)  ;  e,  ex- 
ternal geniculate  body  ;  i,  internal  geniculate  body.  The  dotted  line  which  crosses  the  pons 
Varolii,  connecting  the  roots  of  the  fifth  nerves,  is  Gubler's  line,  an  important  guide,  since 
lesions  of  the/^«.r  in  front  of  it  cause  "crossed  facial  paralysis."  Lesions  in  the  region  of 
the<:rz<jmay  involve  the  third  and  second  nerves  simultaneously.  Lesions  about  the  chiasm 
may  press  upon  the  corpus  striatum  within  the  mass  of  the  cerebrum.  The  crus  comprises 
both  the  motor  and  sensory  tracts  of  the  cerebrum. 


LESIONS   OF   THE   PONS    VAROLII. 

Apoplectic  clots  and  foci  of  softening  are  not  infrequently  met  with 
in  this  region  (Fig.  13),  and  tumors  are  sometimes  encountered.  Certain 
clinical  deductions  of  value  can  be  drawn  from  a  study  of  reported  lesions 
of  the  pons,  as  follows  : — 

The  imaginary  line  that  connects  the  apparent  origin  of  the  tri- 
geminal roots  (line  of  Gubler)  marks  the  level  of  decussation  of  the 
fibres  of  the  facial  nerves  that  pass  cephalad. 

Lesions  above  the  line  of  Gubler  are  liable  to  produce  facial  palsy  and 
hemiplegia  upon  the  same  side  of  the  body  (the  one  opposed  to  the  lesion). 


LESIONS   OF   THE   PONS   VAROLII.  75 

Lesions  below  the  line  of  Guhler  produce  "  crossed  paralysis  of  the 
seventh  nerve  and  body  type,"  the  face  being  paralyzed  upon  tlie  same 
side  as  the  lesion,  while  a  hemiplegia  is  developed  upon  the  opposed  side 
of  the  body. 

The  trigeminus  nerve  may  be  parah'zed  by  lesions  of  the  pons,  if  it 
lies  within  the  inner  two-thirds  of  the  reticular  formation  (according  to 
the  researches  of  Starr). 

If  such  a  lesion  be  situated  high  up  in  the  pons,  trigeminal  paralysis 
will  co-exist  with  a  hemianaesthesia  of  the  opposed  half  of  the  bod}-;  if 
situated  low  in  the  pons,  the  trigeminal  paralysis  and  the  hemianesthesia 
will  be  upon  the  same  side.  The  point  of  union  of  the  ascending  and 
descending  roots  of  the  tifth  nerve  is  nearly  at  the  level  at  which  the  fifth 
nerve  escapes  from  the  pons  (line  of  Gubler). 

Difficulties  of  ai'ficidation  may  often  be  considered  as  diagnostic 
of  lesions  of  the  pons  or  medulla,  provided  the  presence  of  aphasia  of 
cerebral  origin  can  be  excluded  by  the  history  of  the  case.  There  is 
unquestionably  a  tract  of  fibres  (the  motor  speech  tract)  that  serves  to 
connect  the  centres  in  the  medulla  with  the  cortical  centres  for  the  move- 
ments of  the  face  and  tongue. 

Conjugate  deviation  of  the  eyes  may  accompany  a  lesion  of  the  pons. 
This  symptom  is  not  pathognomonic,  however,  because  it  may  occur  also 
with  cortical  lesions  of  the  cerebrum  and  lesions  of  the  internal  capsule. 

The  motor,  sensory,  and  vaso-motor  effects  of  lesions  within  the 
pons  are  manifested  in  the  extremities,  chiefly,  but  not  exclusively,  upon 
the  side  opposed  to  the  lesion.  This  is  not  the  case  with  those  cranial 
nerves  whose  fibres  of  origin  probably  traverse  the  pons  (the  fifth,  sixth, 
seventh,  eighth  [?],  eleventh  [?],  and  twelfth).  The  effects  of  intrapon- 
tine  disease  upon  some  of  these  nerves,  at  least,  are  modified  by  the  seat 
of  the  lesion,  as  has  been  shown  in  preceding  paragraphs. 

Contraction  of  the  pupils  during  an  apoplectic  attack  is  to  be  re- 
garded as  strongly  diagnostic  of  a  clot  within  the  pons. 

Hemorrhage  into  the  jwns  is  usually  followed  by  coma  and  sudden 
death,  if  the  clot  be  large  or  if  the  blood  escape  into  the  fourth  ventricle. 
The  diagnostic  points  mentioned  above  apply,  therefore,  more  particularly 
to  foci  of  softening  and  destructive  lesions  of  small  size  and  slow  devel- 
opment. When  blood  escapes  into  the  fourth  ventricle,  convulsions  are 
observed,  and  death  is  liable  to  follow  rapidly. 

Disturbances  of  the  circidatojy  and  respiratory  functions  may  occur 
in  connection  with  lesions  of  the  pons  ;  but  they  are  to  be  regarded  rather 
as  evidences  that  the  medulla  oblongata  is  directly  implicated  or  sub- 
jected to  pressure. 


76  LECTURES     OX     NERVOUS     DISEASES. 

LESIONS   OF   THE   CEREBELLUM. 

The  functional  attributes  of  this  ganglion  are  as  yet  imperfectly 
determined,  and  the  effects  of  lesions  (tumors,  hemorrhage,  softening, 
atrophy,  and  sclerosis)  which  involve  its  different  regions  vary  with  their 
seat.  The  following  deductions  are  chiefly  those  of  Xothnagel,  who  has 
devoted  special  attention  to  diseases  of  this  ganglion.  Seguin  has  also 
lately  contributed  to  this  field  a  valuable  article. 

Lesions  of  one  of  the  cereheUar  lieminphereH  are  often  incapable  of 
diagnosis,  especially  if  only  one  hemisphere  be  involved. 

Lesions  of  the  vermiform  p?'Oce.%-<  are  generally  attended  with  synij^ 
toms  of  a  more  decided  character. 

Incoordination  of  movement,  an  intense  vertigo  (identical  with  that 
of  ^leniere's  disease),  and  a  "  titubating  gait,''''  are  the  more  common 
effects  of  cerebellar  lesions ;  but  these  are  not  in  themselves  pathogno- 
monic of  cerebellar  disease,  because  they  may  be  produced  by  lesions  of 
other  parts  of  the  brain.  The  consideration  of  all  the  morbid  phe- 
nomena of  each  case  (both  of  a  positive  and  negative  character)  is 
required  to  render  the  diagnosis  certain. 

A  staggering  gait  is  especially  liable  to  be  developed  in  case  the 
"worm"  of  the  cerebellum  is  directly  involved,  or  is  pressed  upon  by 
lesions  of  adjacent  parts.  It  only  exists  when  the  subject  is  in  the  upright 
posture,  and  the  ataxic  sj-mptoms  rarely  affects  the  delicate  movements 
of  the  fingers. 

Gastric  crises  (chiefly  exliibited  by  persistent  vomiting)  are  a  diag- 
nostic feature  of  lesions  of  the  cerebellum,  in  many  cases.  When  de- 
structive lesions  of  the  cerebellum  exist,  vomiting  is  less  frequently 
observed  than  when  that  ganglion  is  encroached  upon  by  lesions  of  other 
parts. 

Atrophy  of  the  cerebellum  has  been  obser\t<]  to  produce  imperfec- 
lions  of  speech   (anarthria).     The  difficulty  seems  to  be  confined  ex 
clusively  to  the  motor  apparatus.     The  memory  of  words  is  not  disturbed. 
It  is  probably  to  be  attributed  to  interference  with  the  "  speech  tract " 
(Fig.  24). 

Pain  in  the  occipital  region  is  often  present  in  cerebellar  disease.  It 
may  exist  also  in  the  frontal  region,  or  be  entirely  wanting. 

The  organ  of  vision  may  be  affected.  Occasionidly,  the  eyes  may 
exhibit  incoordination  of  movement  and  nystagmus ;  and  also  the  evi- 
dences of  choked  disc,  amblyopia,  and  amaurosis. 

Hemorrhage  into  the  cerebellum  is  sometimes  associated  with  a  loss 
of  facial  expression,  due  to  a  slight  paresis.  The  patient  may  also  ex- 
hibit a  tendency  to  assume  one  })Osition.  and  to  return  to  it  when  moved 
by  the  attendants.     Should  hemiplegia  occur,  in  sucli  a  case,  it  indicates 


LESIONS    OF   THE   MEDULLA   OBLONGATA.  77 

thut  the  lesion  exerts  pressure-effects  upon  the  pyramidal  tracts,  either  in 
the  crus,  pons,  or  medulla. 

Irregularity  of  the  hearVs  action^  which  is  sometimes  observed  in 
connection  with  a  cerebellar  lesion,  indicates  a  pressure  upon  the  cardio- 
inhibitor}^  centre  of  the  medulla. 

Abnormal  mental  symptoms  are  generally  absent  in  connection  with 
cerebellar  lesions.  When  atrophy  of  the  organ  is  present,  or  when  other 
parts  of  the  brain  are  diseased  simultaneously  with  the  cerebellum,  mental 
derangements  may  be  observed. 

When  the  middle  crura  of  the  cerebellum  (going  to  the  pons)  are 
affected  by  lesions  which  create  irritation,  rotary  movements  of  the  body 
and  a  lateral  defection  of  the  head  and  eyes  may  be  developed.  As 
a  rule,  these  rotary  movements  are  toward  the  healthy  side  ;  but  this  is 
not  invariably  the  case,  as  they  sometimes  are  toward  the  side  upon 
which  the  lesion  is  situated.  It  is  a  curious  fact  that  most  of  the  etfects 
of  cerebellar  lesions  are  attributable  to  a  greater  or  less  extent  to  irrita- 
tion of  the  crura. 

Lesions  of  the  superior  peduncle  of  the  cerebellum  are  liable  to  in- 
duce paral3^sis  of  the  motor  oculi  nerve,  as  shown  by  the  development  of 
ptosis,  external  strabismus,  and  dilatation  of  the  pupil.  Hemiansesthesia 
and  more  or  less  ataxia  may  be  induced  by  pressure  upon  the  tegmentum 
and  the  fillet  tract  (lemniscus)  respectively. 

^'■Bulbar  symptoms"'  may  develop  late  in  the  course  of  a  cerebellar 
lesion.  Such  phenomena  are  usually  attributable  to  obliteration  of  the 
vertebral  and  basilar  artei'ies  and  their  branches,  as  a  result  of  arteritis 
obliterans  (Seguin). 

LESIONS    OF   THE   MEDULLA   OBLONGATA. 

The  size  of  this  ganglion  almost  precludes  the  existence  of  lesions, 
even  if  small,  which  do  not  influence  to  a  greater  or  less  extent  the  nerve 
nuclei  contained  within  it. 

An  implication  of  the  cranial  nerve  roots  (Figs.  16  and  26)  may 
cause  disturbances  of  respiration,  circulation,  phonation,  deglutition, 
and  articulation. 

The  sensor}'  and  motor  tracts  to  the  extremities  may  be  simulta- 
neously involved ;  and  thus  anaesthesia  (?)  and  paralysis  of  motion  may 
occur  upon  the  side  of  the  body  opposed  to  the  lesion.  The  fillet  tract 
(Fig.  11)  may  be  also  affected  by  the  lesion,  in  which  case  evidences  of 
ataxia  will  be  developed  in  the  extremities.  Finally,  the  lower  part  of 
the  ftice  may  be  rendered  paretic. 

Of  the  above-mentioned  symptoms,  aphonia  and  the  impairment  of 
the  respiratory  and  circulatory  symptoms  are  particularl}'  diagnostic  of 
medullary  lesions. 


78 


LECTURES   ON   NERVOUS  DISEASES. 


The  symptoms  of  Duchenne''s  disease  are  present  onl}'  when  chronic 
progressive  degeneration  of  the  nuclei  of  the  medulla  exists. 

Suddenly  developed  lesions  of  the  medulla  are  liable  to  cause  in- 
stantaneous death. 

Diabetes  and  albuminuria  may  be  excited  b}'  lesions  of  the  medulla. 

When  the  pneumogastric  nerves  are  implicated,  dyspno'a,  irregu- 
larity of  the  action  of  the  heart,  and  gastric  or  intestinal  derangements 
are  encountered. 


a.m.r 


Fig.  27. — A  Transverse  Section  of  the  Medulla  (Partly  Schematic)  Made  Through 
THE  Middle  of  the  Olivary  Body.  (Modified  from  Spitzka.)  H,  and  /;,  nuclei  of  origin 
of  the  hypoglossal  nerve  (twelfth  cranial);  F.  R.,  reticular  formation,  with  its  cell  masses  ; 
O,  olivary  body;  P,  pyramid;  a.  }>i.  /.,  antero-median  fissure;  G  and  Pn,  masses  of  cells 
probably  associated  respectively  with  the  glosso-pharyngeal  and  pneumogastric  nerves;  ]'a, 
ascending  root  of  filth  cranial  nerve;  B,  restiform  column;  a./.,  arcuate  fibres;  /",  fibres 
passing  through  the  inter-olivary  tract;  e  and  d,  bundles  of  fibres  from  the  posterior  spinal 
tracts,  cut  across  on  their  way  to  the  inferior  cerebellar  peduncle  after  decussation  :  7',  the 
"trineural  fasciculus"  of  Spitzka;  "solitary"  or  "round"  bundle  of  other  authors.  Note 
that  the  solid  masses  represented  in  the  cut  in  red  and  yellow  are  composed  of  cells ;  the  black 
areas  are  designed  to  represent  conducting  fibres  running  vertical  to  the  plane  of  the  section  ; 
the  white  lines  represent  fibres  which  run  in  the  plane  of  the  section;  and,  finally,  that  some 
of  the  conducting  strands  are  left  uncolored  (as,  for  example,  T,   la,  F,  e  and  d). 

In  a  few  instances,  tumors  and  foci  of  softening  in  the  medulla  have 
been  known  to  exist  and  create  no  symptoms  of  a  diagnostic  character. 

Dysphasia^  and  the  /o^s  of  the  poiver  of  protrusion  of  the  tongue, 
points  to  an  implicatiou  of  the  hypoglossal  and  glosso-pharyngeal  nuclei. 

FOCAL   LESIONS   INVOLVING   CRANIAL   NERVES. 
In  the  third  edition  of  my  work  upon  "  Surgical  Diagnosis,"*  I  have 
incorporated  some  axioms  which  bear  upon  the  diagnosis  of  focal  lesions 
of  the  bri'in  that  affect  cranial  nerves. 

*  William  Wood  &  Co.,  New  York,  1S8S. 


LESIONS   AFFECTING   THE   OLFACTORY   NERVE. 


79 


Some  of  the  axioms  there  given  require  modification,  when  viewed 
from  the  standpoint  of  our  present  knowledge.  Many  of  the  suggestions 
referred  to  had  been  selected  by  me  from  some  of  my  earlier  writings 
on  this  held,  and,  if  fallen  literally-,  would  now  be  in  conflict  with  later 
observations  of  an  anatomical  and  clinical  character  published  since  that 
date  by  others.  Some  other  points  given  by  me  in  that  work  are  more 
or  less  imperfect,  although  perhaps  technically  accurate.  I  have,  there- 
fore, seen  fit  to  alter  the  wording  of  certain  parts  of  this  work,  which 
I  shall  now  repeat  in  substance  : — 


Fig.  2S. — The  Base  of  the  Skull  with    the   Nerves  which  Escape  from  its  Fora- 
mina.    The  cranial  nerves  are  numbered  in  their  customary  order. 

LESIONS   AFFECTING   THE   OLFACTORY   NERVE. 

Anosmia  (loss  of  smell)  may  occur  from  an}'  lesion  which  involves 
the  first  cranial  nerve.     It  is  usually  unilateral. 

Whenever  it  occurs  in  connection  with  hemiplegia,  the  bod}"  pa- 
ralysis is  on  the  side  opposite  to,  and  the  anosmia  on  the  same  side  as 
the  lesion.  This  condition  is  known  as  crossed  paralysis  of  the  "  first 
cranial  nerve  and  body"  t^-pe.  Anosmia  indicates  the  existence  of  a 
lesion  situated  in  the  anterior  fossa  of  the  cranium,  or  a  destructive 
lesion  of  the  cortex  of  the  temporal  lobe  near  to  its  apex. 


80  LECTUKES   ON   NERVOUS   DISEASES. 

Crossed  jmralysU  of  the  '' olfixctory  nerve  and  body  type"  may 
occur  whenever  a  localized  pressure  is  exerted  chiefly  upon  parts  within 
the  anterior  fossa  of  the  skull.  The  fibres  of  the  so-called  "  motor  tract '' 
(Fio;.  12)  are  involved  by  an  upward  pressure  upon  the  caudate  or  lentic- 
ular nucleus;  or  the  fibres  of  the  internal  capsule  are  directly  affected  by 
the  lesion.  This  accounts  for  tiie  hemiplegia  of  the  opposite  half  of  the 
body.  The  olfactory  nerve  (which  lies  near  the  optic  chiasm)  is  affected 
by  pressure  in  the  downward  direction,  and  the  optic  chiasm  or  tract  may 
be  simultaneously  involved  ;  hence,  a  loss  of  smell  in  the  nostril  on  the 
same  side  as  the  lesion  may  co-exist  with  some  form  of  hemianopsia,  as 
well  as  with  a  crossed  hemiplegia. 

LESIONS   AFFECTING   THE   OPTIC   NERVE. 

Hemianoj)sia  may  occur  when  the  optic  chiasm,  the  optic  tracts,  the 
thalamus,  the  posterior  part  of  the  internal  capsule,  or  the  cortex  of  the  oc- 
cipital lobes  (chiefly  the  cnneus)  are  pressed  upon  or  destroyed.  It  is 
evident,  therefore,  that  the  trephine  cannot  afford  relief  of  this  symptom 
in  most  cases,  because  the  lesion  is  commonly  situated  at  the  base  of 
the  cerebrum.  When  syphilitic  gummata  may  be  suspected,  the  prog- 
nosis is  extremely  favorable  if  active  treatment  be  employed. 

The  variety  of  hemianopsia  may  indicate  the  seat  of  the  lesion  with 
great  exactness.     Fig.  21  will  make  this  apparent. 

\f  ptaralysis  (in  any  of  its  forms)  co-exists  with  hemianopsia,  a  valu- 
able guide  may  often  be  afforded  in  determining  the  extent  of  the  lesion. 

The  hinasal,  and  also  the  bitemporal  varieties  of  hemianopsia  are 
due  (as  a  rule,  at  least)  to  lesions  confined  to  the  anterior  fossa  of  the 
cranium;  hence  we  sometimes  find  the  olfactory  nerve  (of  the  side  cor- 
responding to  the  seat  of  the  lesion)  simultaneous!}'  affected,  and  creating 
anosmia  (loss  of  smell)  with  or  without  subjective  odors. 

If  the  lesion  be  situated  within  the  middle  fossa  of  the  cranium,  the 
optic  tracts  may  be  affected,  thus  causing  homonymous  hemianopsia 
(Fig.  21).  The  motor  nerves  of  the  eye  may  be  simultaneously  pressed 
upon,  as  they  pass  through  that  fossa  on  the  way  to  their  foramen  of 
exit  from  the  cranium  (the  sphenoidal  fissure),  and  thus  more  or  less 
impairment  of  the  movements  of  the  eyeball  of  the  same  side  may  be 
created. 

The  value  of  these  complications  cannot  be  over-estimated,  when 
thej'^  exist,  because  they  may  be  of  the  greatest  aid  in  diagnosis.  Tliey 
may -often  enable  the  skilled  anatomist  to  positively  determine  the  seat 
of  the  lesion. 

Hemiplegia  may  occur  in  connection  with  hemianopsia,  provided 
that  the  lesion  is  of  sufficient  size  to  affect  any  part  of  the  so-called  '"  motor 
tract  ^^  of  fibres  simultaneously  with  the  optic  nerve  fibres  (Fig.  23). 


LESIONS   AFFECTING   THE   OPTIC   NERVE.  81 

Motor  paralysis  is,  under  such  circumstances,  developed  chiefly  if  not 
exclusively  on  the  side  opposite  to  the  lesion,  because  the  fibres  of  the 
motor  tract  decussate,  to  a  greater  or  less  extent,  at  the  lower  part  of 
the  medulla.  Flechsig  has  shown  that,  in  rare  cases,  exceptions  to  this 
rule  are  to  be  explained  by  an  abnormality  in  the  decussation  of  the 
motor  fibres. 

Hemiplegia  is  seldom  observed  in  connection  with  hemianopsia  alone. 

The  olfactory,  motor  oculi,  trigeminus,  or  facial  nerve  roots  are 
especially  liable  to  be  simultaneously  involved.  This  explains  the 
mechanism  of  the  four  varieties  of  "crossed  paralysis"  which  are 
clinically  encountered.  The  hemiplegia  being  developed  on  the  side 
opposite  to  the  lesion  as  a  rule,  while  the  symptoms  produced  by  pa- 
ralysis of  the  cranial  nerve  are  confined  to  the  side  corresponding  to 
the  lesion. 

Homonymous  hemianopsia,  when  it  occurs  without  any  impairment 
of  mobility  or  sensibility,  points  strongly  toward  a  lesion  of  the  cuneus. 

Ataxic  manifestations,  occurring  m  connection  with  evidences  of 
impairment  of  the  sense  of  sight,  open  a  wide  field  for  speculation.  The 
proximity  and  intimate  structural  relations  of  the  cerebellum  with  the 
optic  lobes,  basal  ganglia,  crus,  and  medulla,  suggest  the  possibility  of 
cerebellar  lesions  when  these  two  s3qnptoms  are  present  to  a  marked 
degree,  and  the  patient  can  stand  with  the  eyes  closed. 

Hemianaesthesia  may  occur  in  connection  with  hemianopsia  and 
other  disturbances  of  vision.  It  indicates  some  disturbance  of  the 
nerve  fibres  of  the  so-called  "  sensory  tract ;"  the  loss  of  sensation  being 
confined  to  the  lateral  half  of  the  body  opposite  to  the  lesion  which 
causes  it,  because  the  sensory  fibres  decussate  in  the  spinal  cord. 

In  cerebral  hemianassthesia,  there  is  more  or  less  insensibility  to 
touch,  pain,  and  temperature,  and  also  an  abolition  of  muscular  sensi- 
bility with  complete  retention  of  electro-motor  contractilit3\  The  mu- 
cous membranes  of  the  eye,  nose,  and  mouth  are  also  anaesthetic.  If  it 
be  due  to  hysteria,  the  special  senses  are  either  abolished  or  rendered  defi- 
cient, and  hypersesthesia  over  the  ovaries  exist  (Ferrier).  These  facts 
will  often  enable  the  diagnosis  to  be  made  between  hysterical  and  cere- 
bral heinianjesthesia  of  organic  origin. 

Choked  disc  is  a  common  symptom  of  lesions  situated  at  the  base 
of  the  cerebrum,  and  also  of  any  intra-cranial  disease  which  produces  a 
gradually  increasing  pressure.  It  is  especially  diagnostic  of  cerebral 
tumors. 

It  is  not  associated  with  impairment  of  vision  until  late,  so  that  it 
is  often  unsuspected  when  present.  The  ophthalmoscope  is  necessary 
for  its  detection.  It  may  co-exist  with  hemianopsia,  and  is  always  bi- 
lateral.    It  is  a  positive  contra-indication  to  trephining. 

6 


82  LECTURES   ON   NERVOUS   DISEASES. 

Lesions  at  the  base  of  the  skull  may  cro.s.s  the  menial  line,  and  still 
involve  only  one  optic  tract.  If  this  occurs,  the  hemianopsia  will  l)e 
accompanied  by  other  symptoms  of  diagnostic  importance,  no  longer 
confined  to  one  side.  Double  anosmia,  general  paresis  or  complete  pa- 
ralysis, general  anii'sthesia,  and  paralytic  symptoms  referable  to  both  eye- 
balls might  be  thus  produced.  Lesions  of  this  character  are  more  liable 
to  att'ect  the  chiasm  of  the  optic  nerves  than  the  optic  tracts ;  in  either 
case,  however,  hemianopsia  would  result,  and  its  type  would  be  a  reliable 
guide  to  the  seat  of  pressure. 

Motor  aphasia  aometiines  co-exists  ivith  hemianopsia.  I  have  met 
with  two  instances  of  this  kind.  In  one  there  was  slight  paresis  of  the  left 
side,  tending  to  prove  that  aphasia  can  occur  with  lesions  involving  the 
riglit  hemisphere.  Both  were  cured  with  specific  treatment.  We  must 
attribute  the  development  of  this  complication  to  pressure  upon  parts  in 
the  neighborhood  of  Broca's  centre. 

LESIONS  AFFECTING  THE  MOTOR  OCULI  NERVE. 

The  nucleus  of  orngin  (Fig.  12)  of  the  third  cranial  nerve  of  each 
side  seems  to  be  capable  of  subdivision  into  groups  of  cells  which  pre- 
side over  movements  of  special  muscles  of  the  orbit. 

Tims  we  may  clinically  recognize  the  existence  of  a  special  nucleus 
for  visual  "accommodation,"  for  pupillary  movements,  and  for  the 
internal  rectus,  the  superior  rectus,  the  levator  palpebrae,  the  inferior 
oblique,  and  the  superior  oblique  muscles. 

This  fact  probably  explains  how  the  existence  of  "  external  oph- 
thalmoplegia'''' and  other  distinct  forms  of  orbital  paralysis  may  occiir 
from  organic  lesions  in  the  region  of  the  tegmentum. 

Paralysis  of  this  ne^ve  is  indicated  b}'  the  following  symptoms:  (1) 
a  falling  of  the  upper  eyelid  (ptosis);  (2)  external  strabismus;  (3)  dila- 
tation of  the  pupil;  (4)  a  slight  bulging  of  the  eye  forward,  on  account 
of  muscular  relaxation  ;  and  (5)  a  loss  of  accommodation  of  vision. 

When  the  third  cranial  nerve  is  paralyzed  from  cerebral  lesions 
the  lower  part  of  the  face  is  often  paretic  on  the  same  side  as  the  lesion. 
This  is  not  the  case  when  a  lesion  involves  the  nerve  after  it  escapes 
from  the  crus  cerebri,  viz.,  within  the  middle  fossa  of  the  cranium  or  the 
orbital  cavity 

Crossed  paralysis  of  the  "motor  oculi  nerve  and  body"  type,  indi- 
cates a  lesion  situated  within  the  crus  cerebri.  We  find  that  the  eye  on 
the  same  side  as  the  lesion  can  no  longer  be  turned  tow.ird  the  nose, 
or  made  to  act  in  parallelism  with  the  opposite  eye ;  that  the  pupil  is 
dilated  ;  and  that  the  upper  eyelid  droops  over  the  eyeball,  giving  it  a 
sleepy  appearance.  On  the  side  opposite  to  the  lesion  the  body  is  hemi- 
plegic.     There  are  few  conditions  which  are  of  greater  clinical  importance 


LESIONS    AFFECTING   THE   CRANIAL   NERVES.  83 

than  this  type  of  crossed  paralysis,  because  the  seat  of  the  lesion  is  posi- 
tively indicated. 

If  the  optic  tract,  which  lies  in  close  relation  with  the  cms  be 
simultaneously  affected  by  the  lesion,  the  evidences  of  "  homonymous 
hemianopsia,"  will  be  superadded,  viz.,  the  eye  on  the  same  side  as  the 
lesion  will  be  blind  in  its  temporal  half,  and  that  of  the  opposite  side 
in  its  nasal  half. 

One  half  of  the  pupil  may  fail  to  react  to  light  when  hemianopsia 
exists.     This  is  known  as  the  "  hemiopic  pupillarij  i-eaction.''^ 

LESIONS   AFFECTING   THE   FOURTH   AND    SIXTH   CRANIAL   NERVES. 

The  nerves  which  are  associated  with  the  movements  of  tlie  eyeball 
— the  third,  fourth,  and  sixth  cranial — pass  through  the  middle  fossa  of 
the  cranium  in  company  with  the  fifth  cranial  nerve.  For  this  reason, 
lesions  situated  at  tlie  base  of  the  brain  are  liable  to  involve  any  of 
these  nerves  separately,  or  all  simultaneously,  according  as  its  pressure- 
effects  are  felt  in  one  direction  or  another. 

In  addition  to  cranial  causes,  lesions  of  the  orbit  may  also  create 
impairment  of  the  third,  fourth,  ophthalmic  branch  of  the  fifth,  or  sixth 
cranial  nerves — all  of  which  pass  through  the  sphenoidal  fissure  into  the 
orbit. 

Impairment  of  the  sixth  cranial  nerve  is  indicated  by  the  develop- 
ment of  intei-nal  strabismus ;  the  extent  of  which  varies  with  the  degree 
of  the  paralysis. 

If  this  nerve  be  affected  by  lesions  within  the  cranium,  other  nerves 
are  liable  to  be  simultaneously  involved  ;  and  an  impairment  of  the  cere- 
bral motor  tract  may  also  be  evidenced  by  a  co-existing  hemiplegia  or 
paresis  of  the  side  of  the  body  opposite  to  the  seat  of  the  lesion. 

LESIONS   AFFECTING   THE   FIFTH   CRANIAL   NERVE. 

The  following  propositions  will  cover  the  diagnostic  points  which 
relate  to  lesions  of  the  trigeminal  nerve  (after  it  escapes  from  the  pons). 

Peripheral  lesions  cause  anaesthesia  of  special  parts  supplied  by 
small  branches  or  single  filaments  of  the  nerve. 

The  co-existence  of  paralysis  of  other  cranial  nerves  with  anes- 
thesia of  the  face,  indicates  a  lesion  in  the  vicinity  of  the  base  of  the 
cerebrum. 

If  a  part  of  the  face  and  the  corresponding  facial  cavity  (orbital, 
nasal,  or  buccal)  are  simultaneousl}'^  affected  with  a  loss  of  sensation,  the 
lesion  is  within  the  cranium,  and  so  situated  as  to  involve  one  of  the 
three  main  divisions  of  the  nerve. 

If  the  anaesthesia  extends  over  the  entire  area  supplied  by  all  of 
the  branches  of  the  nerve,  and  evidences  of  disturbance  in  the  nutrition 


84  LECTURES   ON   NERVOUS   DISEASES. 

of  the  parh  are  also  present,  the  lesion  affects  the  ganglion  of  Gasser  or 
its  immediate  neighborhood. 

If  the  muscles  of  mastication  are  paralyzed,  and  no  anaesthesia 
exists,  the  lesion  is  outside  of  the  cranium  and  involves  onh'  the  motor 
root  of  the  inferior  maxillary  branch  of  the  nerve. 

The  anterior  two-thirds  of  the  tongue,  the  mucous  lining  of  the 
floor  of  the  mouth,  and  the  integument  of  the  chin  will  be  rendered 
aUtTesthetic  simultaneously  if  the  sensory  trunk  of  the  inferior  maxillary 
nerve  is  involved ;  and  taste  may  be  affected  also  on  the  same  side  as  the 
sensory  paralysis. 

Neuralgia  of  the  various  branches  of  the  fifth  nerve  may  exist  in 
place  of  anaesthesia,  whenever  the  lesion  simply  irritates  the  nerve  trunks, 
but  does  not  impair  their  power  of  conduction  of  sensory  impulses. 

All  late  authorities  agree  in  the  statement  that  the  deep  trigeminal 
fibres  may  be  traced  as  two  roots:  the  so-called  descending  root  (which 
comes  from  the  cerebrum),  and  the  ascending  root,  which  is  apparent  in 
cross-sections  at  different  levels  of  the  medulla.  The  view  of  Meynert, 
that  the  fibres  of  the  descending  root  cross  within  the  substance  of  the 
pons,  is  sustained  by  clinical  facts,  as  shown  by  Starr.  This  author 
draws  the  following  deductions,  respecting  the  clinical  significance  of 
facial  anaesthesia : — 

1.  Lesions  affecting  the  ascending  root  of  the  trigeminus  produce 
anaesthesia  of  the  face  ui:)on  the  same  side  as  the  lesion. 

2.  Lesions  affecting  the  descending  root  of  the  trigeminus  produce 
an.nesthesia  of  the  face  upon  the  side  opposed  to  the  lesion. 

3.  Disturbances  of  sensibility  in  the  face  indicate  a  lesion  situated 
within  the  medulla  or  pons,  and  in  the  external  lateral  part  of  the  for- 
matio  reticularis  (provided  it  be  not  due  to  neuritis  of  the  trigeminus  or 
a  cerebral  lesion). 

4.  If  the  face  he  rendered  anaesthetic  upion  one  side.,  and  the  body 
upon  the  opposite  side  (the  condition  known  as  "  crossed  sensor}'  pa- 
ralysis"), the  lesion  affects  the  entire  extent  of  the  formatio  reticularis, 
and  lies,  in  the  medulla  or  pons,  below  the  point  of  union  of  the  ascend- 
ing and  descending  roots  of  the  trigeminus. 

5.  If  the  face  and  limbs  be  rendered  anaesthetic  upon  the  same  side. 
the  lesion  lies  in  the  brain  at  a  point  higher  than  the  junction  of  the  two 
roots  of  the  trigeminus.  It  may,  therefore,  be  found  within  the  formatio 
reticularis  of  the  vpjoer  part  of  the  pons  and  cms,  or,  if  cephalad  of  the 
crus,  it  may  affect  the  posterior  third  of  the  internal  capsule  of  the  cor- 
responding cerebral  hemisphere,  the  centrum  ovale  of  that  hemisphere, 
or  tlie  sensory  area  of  the  cerebral  cortex,  in  which  all  the  sensory  tracts 
terminate. 


LESIONS   AFFECTING   THE   CEANIAL   NERVES.  85 

LESIONS    OF   THE   SEVENTH    CRANIAL   NERVE. 

The  following  propositions  will  cover  the  diagnostic  points  of  lesions 
which  induce  facial  paralysis  (BeWs palsy) : — 

If  the  paralysis  be  limited  to  distinct  jyarts  of  one  lateral  half  of 
the  face^  the  lesion  atfects  only  individual  branches  of  the  nerve,  and  is 
outside  of  the  cranium.  An  apparent  exception  to  this  rule  is  sometimes 
met  with  in  connection  with  lesions  of  the  internal  capsule  and  of  the 
eras  cerebri — paralysis  of  the  lower  half  of  one  side  of  the  face  being 
clinically  observed  to  occasionally  accompany  hemiplegia,  and  also  pa- 
ral3'sis  of  the  motor  oculi  nerve  on  the  same  side  as  the  lesion. 

If  the  fauces  and  jjalate  exhibit  paralytic  changes  the  lesion  is  within 
the  cranium  or  in  the  temporal  bone. 

If  the  sense  of  taste  be  lost  in  the  anterior  two-thirds  of  the  lateral 
half  of  the  tongue  (on  the  same  side  as  the  general  facial  paralysis),  the 
lesion  is  either  within  the  cranium,  or  in  the  temporal  bone  above  the 
origin  of  the  chorda  tympani  branch. 

If  the  sense  of  hearing  is  rendered  very  acute  upon  the  same  side 
as  the  facial  paralysis,  the  lesion  is  probably  wdthin  the  temporal  bone 
and  involves  the  ganglionic  enlargement  found  upon  the  nerve  in  the 
aqueduct  of  Fallopius. 

Facial  paral^-sis  (when  dependent  upon  cerebral  lesions,  or  those 
of  the  crus  cerebri  or  the  2}ons)  is  commonly  associated  with  hemiplegia, 
which  may  be  upon  the  same  side  as  the  lesion  or  on  the  opposite  side. 

Crossed  jMralysis  of  the  "  facial  nerve  and  body  type"  indicates  a 
lesion  of  the  pons  Varolii  posterior  to  the  line  which  connects  the 
trigeminus  nei've  with  its  fellow  at  their  escape  from  the  pons.  (Gubler.) 
The  reader  is  referred  to  Fig.  27. 

If  the  lesion  be  situated  in  front  of  Gubler's  line,  the  facial  pa- 
ralysis and  the  hemiplegia  will  be  on  the  same  side. 

LESIONS   AFFECTING   THE    CRANIAL   NERVES    ARISING   FROM   THE 
MEDULLA   OBLONGATA. 

The  facial,  :iuditory,  glosso-pharyngeal,  pneumogastric,  spinal  ac- 
cessory, and  hypoglossal  nerves  have  their  apparent  origin  from  the 
medulla,  and  are  more  or  less  imperfectly  understood  in  regaixl  to  their 
connection  with  different  parts  of  the  encephalon. 

Lobio-glosso-pharyngeal  i)aralysis  ("Duchenne's  disease"  or  "bulbar 
paralysis")  is  associated  with  successive  destruction  of  the  nerve  nuclei 
in  the  floor  of  the  fourth  ventricle  and  a  secondary  degeneration  of  the 
nerve  trunks  connected  with  them. 

The  nerve  which  exhibits  the  first  evidences  of  paralysis  will  often 
afford  clinical  data  from  which  some  deductions  respecting  the  original 


86  LECTUKES    OX    NERVOUS   DISEASES. 

seat  of  the  lesioii  may  be  drawn.  The  more  common  lesions  of  the 
medulla  include  arteritis,  thrombosis,  traumatism,  softening,  hemorrhage, 
sclerosis,  and  tumors. 

The  development  of  '•  bulbar  paralysis  "  is  associated,  as  a  rule,  with 
neuralgic  pains,  muscular  spasms,  anaesthesia,  and  disorders  of  special 
senses. 

Compression  of  the  medulla  oblongata  has  1)een  shown  to  cause  the 
respiratory  phenomena  termed  "  Cheyne-Stokes  respiration,"  and  also 
albuminous  and  diabetic  urine.  In  the  former,  the  frequency  and  char- 
acter of  respiration  constantly  changes  in  some  regular  order — gradually 
increasing  to  a  certain  maximum,  and  then  gradually  decreasing  in  fre- 
quency till  the}'  cease,  when  the}'  begin  again  to  increase  in  frequency 
and  in  depth. 

The  vaso-motor  centres,  which  are  situated  within  the  medulla,  help 
to  explain  many  other  visceral  phenomena  which  are  observed  when  it  is 
diseased.  These  are  too  numerous  and  complex  in  their  nature  to  be 
discussed  here. 

The  differential  diagnosis  of  suddenh'-developed  lesions  of  the 
medulla,  which  are  not  immediately  fatal,  must  rest  upon  the  co-exist- 
ence of  certain  functional  disturbances.  Among  these  may  be  chiefly 
mentioned:  1,  epileptiform  attacks,  occurring  at  the  onset  or  later;  2, 
hemiplegia  or  paraplegia;  3.  loss  of  consciousness;  4,  hypera'sthesia  or 
circumscribed  anaesthesia ;  5,  dysphagia,  vomiting  or  hiccough,  and 
Cheyne  Stokes  respiration,  from  interference  with  the  pneumogastric 
nerve;  6.  embarrassment  of  speech,  from  interference  with  the  hypo- 
glossal nerve;  *l .  deflection  of  the  velum  palati  and  uvula,  from  interfer- 
ence with  the  f;\cial  nerve ;  8,  hydruria,  from  interference  with  the  centre 
of  renal  circulation  ;  9,  diabetes,  probably  from  interference  with  the 
centre  of  the  vasomotor  nerves  of  the  liver;  10,  normal  electro-mus- 
cular contractility  in  the  paralyzed  parts. 

If  the  lesion  be  very  extensive  and  of  sudden  advent,  death  may 
occur  without  the  bulbar  symptoms  being  well  defined. 

A   SUMMAEY  OF  THE  MORE  IMPORTANT  PHYSIOLOGICAL  AND  PATHO- 
LOGICAL  FACTS   PERTAINING   TO   THE   SPINAL   COED.* 

Much  of  an  anatomical  nature  relating  to  the  spinal  cord  might  be 
introduced  at  this  point  with  profit  to  the  reader  if  space  would  permit. 
It  is  hoped,  however,  that  by  the  aid  of  the  diagrams  incorporated,  the 
various  "  tracts  "  or  bundles  of  fibres  which  compose  the  cord  will  be 
comprehended.     Additional  information  of  an  anatomical  kind  may  be 

*  Some  parts  of  this  section  have  already  appeared  in  the  chapter  upon  the  Diseases 
of  the  Spinal  Coi-d  in  the  last  edition  of  the  Author's  work,  "  A  Practical  Treatise  on  Sur- 
gical Diagnosis."     William  Wood  A:  Co.,  N.  Y.,  1884. 


SUMMARY    OF   FACTS   PERTAINING   TO   THE   SPINAL   CORD.        87 


Fig.  29. — A  Diagrammatic  Representation  of  the  Conducting  Tracts  op  the  Spinal 
Cord.     (Modified  from  Hramwell. )      /,  fibres  of  Tiirck's  column  (direct  pyramidal  bundle) ; 

C.  P.,  "crossed  pyramidal  fibres;"   G,  fibres  of  the  column  of  GoU  (postero-median  column! ; 

D.  C,  fibres  of  the  "direct  cerebellar  column."  Note  that  the  arrows  show  the  direction  of 
the  impulses  carried  by  each  tract  of  fibres.  Also  that  the  motor  fibres  of  the  lateral  column 
decussate  at  the  loiver  fart  of  the  iiiednlla.  Each  of  the  "anterior  pyramids"  of  the 
medulla  is  composed  of  the  motor  iibres  (direct  and  decussating)  above  the  lower  limits  of 
the  medulla. 


88  LECTURES   ON   NERVOUS   DISEASES. 

gained  by  tlie  reader  (in  case  the  diagrams  prove  insnfRcient)  by  refer- 
ring to  the  introductory  pages  of  a  subsequent  section  which  treats  of 
diseases  of  the  spinal  cord. 

1.  The  anterior  and  lateral  pyramidal  coJuni)}.^  of  each  side  con- 
tain only  motor  fibres.  Those  in  the  former  (Tiirck's  columns)  are  con- 
nected with  the  corresponding  cerebral  hemisphere ,  while  those  of  the 
latter  (the  '' crossed  pyramidal  tracts")  are  connected  with  the  opposite 
cerebral  hemisphere.     (Fig.  29.) 

2.  Tlie  posterior  column  of  each  side  (comprising  two  portions — 
that  of  Goll  and  Burdach)  serves  to  convey  sensory  nerve  fibres  appa- 
rently connected  with  the  tactile  sense,  and  also  commissural  fibres  (?) 
which  connect  different  segments  of  the  cord ;  hence  the}'  are  physiologi- 
cally associated  both  with  tactile  sensation  and  the  coordination  of  mus- 
cular movement.     (Fig.  29.) 

3.  The  lateral  column  of  each  side  (exclusive  of  the  crossed  pyra- 
midal fibres  and  those  of  the  direct  cerebellar  column)  probably  conveys 
vaso-motorfibres  and  possibly  those  of  sensation  also.  It  has  been  proven 
also  to  convey  fibres  directl}'  to  the  cerebellum  (the  ^^ direct  cerebellar 
column'''').  The  crossed  jiyramidal  tract  occupies  a  distinct  area  of  this 
column. 

4.  The  multipolar  nerve  cells  in  the  anterior  horn  of  the  spinal 
gra}'  matter  possess  a  "trophic  function.''''  When  they  are  destro3'ed, 
the  nerve  fibres  arising  from  them,  and  the  muscles  also  which  are  sup- 
plied by  those  fibres,  undergo  atrophy.     (Fig.  33.) 

5.  The  fibres  of  the  anterior  and  lateral  pyramidal  columns  have 
their  "trophic  centre"  in  the  motor  area  of  the  cerebral  cortex.  Any 
lesion  which  tends  to  sever  these  fibres  from  this  centre  creates  a  de- 
scending degeneration  of  all  the  nerve  fibres  so  disconnected,  as  far  as 
their  ultimate  distribution,  viz.,  to  segments  of  cord  below  the  lesion. 

6.  The  spinal  nerves  may  be  regarded  as  guides  to  the  various 
segments  of  the  spinal  cord ;  each  segment  consisting  of  a  disc  of  the 
cord  of  sufficient  thickness  to  include  a  separate  pair  of  spinal  nerves 
which  are  attached  to  it.     (Fig.  31.) 

7.  Each  spinal  segment^  with  its  attached  nerves,  may  be  figura- 
tively regarded  as  a  distinct  spinal  cord  for  that  limited  portion  of  the 
body  to  which  its  nerves  are  distributed,  viz.,  the  muscles  to  which  the 
anterior  roots  of  the  spinal  nerves  proceed,  and  the  j^arts  siqjpUed  with 
sensation  by  means  of  the  posterior  roots  of  the  same. 

8.  The  .superimposed  segments  of  the  cord  are  bound  together  by 
tracts  of  nerve  fibres.  Some  of  these  are  continued  into  the  brain,  while 
others  are  purely  commissural  in  type.  We  can  attribute  to  the  former 
o-roup  (the  "  motor"  and  "  sensory  tracts")  the  conduction  of  motor  im- 
pulses from  the  brain  to  the  various  spinal  segments,  and  of  impressions 


SUMMAKY   OF   FACTS    PEKTAINING   TO   THE   SPINAL   CORD. 


89 


of  a  sensory  character  IVoiu  the  periphery  of  the  body  to  the  brain  itself 
The  other  group  mentioned  (the  "  associating  fibres  ")  serves  to  assist  the 
different  spinal  segments  in  the  performance  of  all  acts  where  a  har- 
monious and  simultaneouH  action  of  several  segments  of  the  spinal  cord 
IS  demanded. 

9.  The  two  lateral  halves  of  each  segment  of  the  spinal  cord  are 
not  totally  distinct  from  each  other,  because  a  connecting  band  of  the 
gray  substance  of  the  cord  (the  gray  commissure),  and  also  one  of 
white  substance  (the  white  commissure),  bind  them  together.  The 
white  commissure  lies  at  the  bottom  of  the  anterior  median  fissure ;  the 
gray  commissure  fills  the  remaining  space  between  the  anterior  and 
posterior  median  fissures  (Fig.  30). 

10.  The  anterior  horns  of  the  spinal  gray  matter  contain  cells  of 
large  size  which  are  connected  (1)  with  motor  nerve  fibres,  joining  each 
spinal  segment  with  the  brain  (somewhat  indirectly),  and  (2)  with  the 
fibres  of  the  anterior  root  of  the  spinal  nerve  (associated  with  the  muscles 
controlled  by  each  segment).     Thus  these  nerve  cells  are  interposed  be- 


FiG.  30.— A  Spinal  Segment.     The  two  roots  of  the  spinal  nerve  are  shown  ;  also  the  sensory 
and  motor  fibres  of  which  each  is  composed. 

tween  the  fibres  which  pass  from  the  brain  to  the  cord  and  those  dis- 
tributed to  the  muscles,  an  arrangement  Avhich  permits  of  an  automatic 
action  of  the  cord,  irrespective  of  cerebral  influences. 

The  cells  of  the  anterior  horns  appear  to  control  also  the  nutrition 
of  the  muscles,  connected  with  them  by  means  of  the  nerve  fibres. 

11.  The  cells  of  the  posterior  horns  and  central  portion  of  the  spinal 
gray  matter  are  probably  connected  more  or  less  intimately  with  the 
fibres  of  the  posterior  or  sensory  roots  of  each  sjnnal  segment,  and 
possibly  also  with  the  p)ath.s  of  conduction  of  painful  impressions  to  the 
brain.  They  do  not  exert  any  apparent  infiuence  upon  the  nutrition  of 
the  parts  associated  with  them  by  means  of  the  spinal  nerve  fibres. 

12.  The  spinal  reflexes  are  probably  performed  by  means  of  an 
anastomosis  of  the  processes  of  the  cells  of  the  anterior  and  posterior 
horns  of  each  lateral  half  of  a  spinal  segment.     This  enables  a  sensory 


90 


LECTURES    ON    NERVOUS   DISEASES. 


MOTOR. 


St. -Mastoid 
Trapezius 

Diaphragm 


r  Flexors,  hip 

E.xtensors,  knee 
Abductors  "] 


SENSORY. 

f   Neck  and  scalp 
[   Neck  and  shoulder 

Shoulder 
r"  Arm 
Hand 


Thigh     <( 


front 


J-hip 


;.  Adductc 


1   ^     f    I    Extensors(?)  J 

Flexors,  knee  (?) 

Muscles      of     leg 
moving  foot 


REFLEX. 


Scapular 


Front  of  thorax 
>   Ensiform  area 


Abdomen 
(Umbilicus  10th) 


f  Buttock,  upper 

I  Groin  and  scrotum 

S       front 

~|  f  outer  side 


(   Perineal     and     Anal   }   p^.j^g.^^  ^„a  Anus 
4         )       Muscles  ^ 


(  Skin 

^       Ar 


from  coccyx  i< 
Anus 


Epigastric 


Abdominal 


inner  side 
Leg,  inner  side 
C  buttock,  lower 
I        P'^'' 


Back  of  Thigh 
L^S     ^        except 

^  i    inner  part 

Foot    5 


-  Cremasteric 
Knee  reflex 


)-  Gluteal 


Foot  clonus 
Plantar 


F,r  '^^  —A  Diagram  Designed  to  Show  the  Relations  of  the  Vertebra  to  the 
Sp"s?gments,  and  op  the  Spinal  Nekves  to  the  Motor.  Sensory,  and  Reflex 
Functions  of  the  Spinal  Cord.     (Govveio.  ) 


SUMMARY   OF   FACTS   PERTAINING   TO   THE    SPINAL   CORD.        91 

imprei>iiion^  which  is  conveyed  to  the  spinal  seumeut  b}^  means  of  tlie 
fibres  of  tlie  posterior  root  of  tlie  spinal  nerve,  to  become  transformed 
into  motor  impulses  in  the  cells  of  the  anterior  horn.  These  are  then 
transmitted  to  the  mnscles  b}'  the  fibres  of  the  anterior  root  of  the  spinal 
nerve. 

13.  The  sense  of  touch  may  be  destroyed,  in  parts  below  the  point 
of  injury,  by  section  or  disease  of  the  posterior  columns.  The  sense  of 
pain  and  the  appreciation  of  temperature  are  apparently  still  conducted, 
provided  the  jiray  matter  escapes  injury. 

14.  The  sense  of  pain  is  destroyed  when  the  grai/  matter  is  rendered 
incapable  of  transmitting  such  sensations.  The  sense  of  touch  ajiparently 
remains  unuliected,  if  the  posterior  columns  escape. 

15.  The  sensation  of  pain  and  of  touch  may  l)e  independently  re- 
tarded l)y  lesions  of  the  cord  that  impair,  but  do  not  totally  destroy  the 
conductivity  of  the  paths  for  such  sensations.  The  amount  of  such 
retardation  depends  upon  the  extent  of  the  destructive  process  within 
the  cord.  Cases  have  been  reported  where  thirty  or  more  seconds  would 
elapse  between  each  painful  contact  on  the  periphery  of  the  body  and  its 
appreciable  sensation. 

16.  Destruction  of  a  joosterior  root  of  a  spinal  nerve,  or  the  net- 
work of  fibres  formed  by  it  within  the  substance  of  the  cord,  must  affect 
the  transmission  of  all  sensations  of  touchy  2:)ain^  and  temperature  from 
the  peripheral  area  of  distribution  of  the  nerve  so  affected  (Fig.  31). 

n.  Destruction  of  a.  posterior  nerve  root  causes  anaesthesia  to  pain, 
temperature,  and  touch.  Trophic  disturbances  of  the  skin  are  also  liable 
to  follow,  particularly  if  the  nerve-root  is  injured  outside  of  the  gang- 
lionic enlargement  developed  upon  it  (Fig.  30). 

18.  Destruction  of  the  columns  of  Burdach  and  Goll  is  followed 
b}'  tactile  anaesthesia  of  definite  areas,  that  correspond  to  t^ie  spinal  seg- 
ments afiected,  and  sometimes  in  parts  below  the  injury.  Anaesthesia  of 
the  arms  is  especially  characteristic  of  a  lesion  in  Burdach's  column; 
when  in  the  legs,  of  Goll's  column. 

1',).  When  the  posterior  cDJuniDs  of  the  cord  are  affected  with  dis- 
eased conditions  that  create  irritation  of  tiie  parts,  the  so-called  ''  girdle 
j/ain^^^  or  "cincture-feeling''''  is  developed  in  those  nerves  that  traverse 
the  disease  area  of  the  cord.  Below  the  level  of  the  spinal  lesion,  sub- 
jective sensations  of  touch  (such  as  formication,  numbness,  abnormal 
sensations  of  heat  or  cold,  etc.),  and  more  or  less  hypersesthesia  are 
usually  created. 

20.  Lesions  of  the  sensory  tracts  (the  so-called  "  aesthesodic  sys- 
tem") cannot  induce  paresis,  paralysis,  spasm,  or  muscular,  atrophy. 
They  can  onl}-  create  sensory  manifestations  (such  as  anaesthesia,  hyper- 
a?sthesia,  numbness,  formication,  abnormal  sensations  of  heat  and  cold. 


92 


LECTUKES    ON    NEKV0U8   DISEASES. 


Fig.  32. — A  Diagram  Designed  to  Illustrate  the  Connections  of  the  Motor  and 
Sensory  Conducting  Tracts  of  the  Cord  with  the  Spinal  Nerves.  (Modified 
from  Bramwell.)  M,  motor  fibres  of  the  anterior  root  of  a  spinal  nerve ;  S,  S',  sensory  fibres 
of  the  posterior  root.  Note  that  the  course  of  5'  and  S'  are  not  the  same.  Some  sensory 
fibres  pass  directly  through  the  posterior  horn  of  the  spinal  gray  substance,  and  others  through 
Burdach's  column  to  read  the  gray  substance.  The  direct  cerebellar  column  is  composed  of 
fibres  which  start  in  Clarke's  column  of  cells  (Fig.  33).  The  fibres  of  the  two  pyramidal 
tracts  become  united  to  the  motor  cells  in  the  anterior  horns  of  the  spinal  gray  substance. 


SUMMARY   OF   FACTS   PERTAINING   TO   THE    SPINAL   COED.        93 

and  pain),  and,  in  tiddition,  tin  inability  to  properly  coordinate  ninscular 
movements  (ataxic  symptoms). 

21.  Sensory  phenomena  are  manifested,  as  a  rule,  upon  the  side  of 
the  body  opposed  to  the  seat  of  the  lesion.  If  they  occur  upon  the  same 
side,  either  the  posterior  nerve  roots  are  directly'  involved,  or  the  sensory 
tracts  are  affected  during  their  ascent  in  the  posterior  columns  before 
their  decussation. 

22.  The  so-called  "  cincture  feeling  "  or  "  girdle  j)o.in  "  may  be  taken 
as  a  valuable  guide  in  deciding  as  to  the  probable  limits  of  a  focal  lesion 
of  the  cord. 

23.  Pain  in  the  region  of  the  spine  is  a  rare  symptom  of  disease  of 
the  spinal  cord.  When  it  exists,  it  commonly  indicates  a  disease  pro- 
cess that  is  confined  to  the  vertebrae  or  the  spinal  meninges. 

24.  Destructive  lesions  of  the  posterior  columns  (if  bilateral)  are 
commonly  associated  with  a  hand  of  complete  ansesthesia  that  corre- 
sponds to  the  area  of  distribution  of  nerve  roots  afiected  by  the  lesion. 
Below  this  girdle  of  anjesthesia,  sensations  of  touch  are  usually  impaired 
or  absent,  and  sensations  of  pain  are  localized  with  difficult}',  but  are  still 
transmitted  b}^  the  gra}'  matter  of  the  cord. 

25.  Lesions  that  create  irritation  of  the  cervical  gray  substance  are 
accompanied  by  dilatation  of  the  i)upil.  If  destructive  processes  are 
subsequently  developed,  the  pupil  becomes  contracted  (Argyll  Robert- 
son's pupil). 

20.  Lesions  of  the  posterior  columns  tliat  irritate  primarily  and 
sul)sequently  destroy  the  spinal  substance  tend,  as  a  rule,  to  progress 
upward.  As  they  advance,  the  girdle  of  pain  travels  upward  and  leaves 
behind  it  a  girdle  of  anoesthesia  that  steadily  increases  in  widtli.  In 
l)arts  situated  below  the  level  of  the  lesion,  the  sense  of  touch  is  usually 
lost,  although  subjective  sensations  of  touch,  such  as  formication,  ting- 
ling, numbness,  etc.,  may  exist. 

27.  The  existence  of  a  girdle  jxiin,  without  any  impairment  of  the 
sense  of  touch  in  parts  below  it,  or  the  presence  of  motor  paralysis, 
points  strongly  to  some  lesion  that  involves  the  posterior  nerve  roots 
only. 

28.  Lesions  that  affect  only  the  motor  tracts  (the  so-called  "  kine- 
sotUc  system")  may  induce  paresis  or  paralysis,  spasm,  and  atrophy  of 
muscles.  They  never  cause  sensoiy  symptoms  (such  as  marked  and  per- 
numeut  pain,  h^-pemesthesia,  ansesthesia,  numbness,  formication,  etc). 

29.  Paralysis  of  motion  and  muscular  atrophy^  when  due  to  spinal 
lesions,  develop  upon  the  same  side  of  the  body  as  the  lesion.  The  same 
is  generally  true  of  the  symptoms  referable  to  incoordination  of  move- 
ment,— the  so-called  "  ataxic"  sj-mptoms.  The  fibres  that  convey  the 
"  muscular  sense"  do  not  decussate  until  they  reach  the  medulla. 


94 


LECTURES    UN    NEliVOUS   DISEASES. 


30.  Atrophii-  chungi'.^  in  luuscles  points  strongly  toward  a  degen- 
eriitive  change  in  tiie  motor  )irrve-cells  of  tlie  anterior  horns  of  the  spinal 
gray  matter.  These  cells  are  the  trophic  centres  for  the  fibres  of  the 
anterior  nerve  roots.     (Fig.  33.) 

31.  Contrdci lire,  or  a,  permaneirt  sJwrtening  of  paralyzed  muscleii, 
is  strongly  diagnostic  of  a  lesion  that  involved  the  "crossed  pyramidal 
tract"'  within  the  lateral  column  of  the  cord.     (Fig.  29.) 

32.  Si/inpfoin.^  referable  to  sjjecial  organs  (when  dependent  upon  a 
spinal  lesion)  indicate  that  some  of  the  special  centres  of  the  cord  are 
involved.  Such  symptoms  may  be  of  value  in  determining  the  extent 
and  situaticjH  of  the  lesion. 


Fig.  3:3. — SEMi-niAGKAMMAxic  Transverse  Section  of  the  Gray  Substance  of  the 
Cekvical  {A)  ANn  Lumbar  Enlargement  (B)  of  the  Spinal  Cord.  (Erb.)  A.  a, 
median  group  of  cells;  6,  antero-lateral  group;  c,  postero-lateral  group  ;  d.  vesicular  column 
of  Clarke.  B.  a,  median  group;  a',  group  that  appears  first  in  the  lumbar  region,  possibly, 
belonging  to  a  ;  b,  antero-lateral  group ;  c,  postero-lateral  group.  Note  that  the  cells  are 
few  and  scattered  in  the  posterior  horns,  and  also  that  the  shape  of  both  horns  differs 
markedly  in  A  and  B. 


33.  Lesions  of  the  so-called  "  motor  tracts''''  of  the  cord  (the  "  kine- 
sodic  system"),  if  destructive  in  character  and  sutlieiently  large  to  sever 
the  connection  of  the  motor  fibres  from  their  connection  with  the  cells  of 
the  cerebral  cortex,  produce  complete  parah'sis  of  motion  below  the  level 
of  the  lesion  on  the  corresponding  side  of  the  l)ody.  The  paralyzed 
muscles  will  probabh'^  undergo  subsequent  contracture,  and  the  deep  or 
tendon-reilexes  will  become  exaiiuerated. 


SUMMAKY   OF   FACTS   PEllTAINING   TO   THE   SPINAL   CORD. 


95 


34.  Lemons  of  the  anterior  horn  of  the  spinal  gray  matter  are  liable 
to  produce  paralysis  in  the  areas  of  distribution  of  the  related  nerves, 
without  disturbance  of  sensibility,  but  with  marked  trophic  disturbances. 

35.  Slight  pressure  upon  the  cord  may  induce  moderate  paral^'sis 
(paresis)  of  the  extensor  muscles  and  secondary'  contracture  of  the 
flexors. 

36.  Lesions  of  one  lateral  half  of  the  cord  produce  complete  motor 
paralysis,  vaso-motor  disturbances,  incoordination  of  movement,  and 
hyperaesthesia  on  the  corresponding  side  below  the  level  of  the  lesion, 
and  a  loss  of  sensibility  on  the  opposite  side  with  more  or  less  paresis 
in  some  cases.  A  zone  of  anaesthesia,  surmounted  by  one  of  hyper^es- 
thesia,  may  exist  at  the  level  of  the  lesion  on  the  corresponding  side. 


Fig.  34. — A  Diagram  Designed  by  the  Author  to  Illustrate  the  Various  Channels 
Through  which  a  Motor  Cell  of  the  Cord  may  be  Called  into  Action. — A.  H., 
anterior  horn  ;  C.  P.  C,  crossed  pyramidal  column;  P.,  posterior  horn  ;  B.,  column  of  Bur- 
dach;  G.,  column  of  Goll ;  1,  fibre  for  pain  sensations;  2,  fibre  for  touch,  tendon,  etc.  ;  3, 
motor  cell ;  4,  motor  fibres  ;  .5,  fibre  from  opposite  cerebral  hemisphere  going  to  cell  (.S);  (5, 
ganglion,  or  posterior  nerve  root ;  7,  fibre  from  cerebral  hemisphere  of  same  side,  going  to 
cell  (3). 

37.  Complete  compression  or  division  of  the  spinal  cord  causes  an 
exaggeration  of  the  reflexes  of  the  spinal  segments  below  the  seat  of 
injury  on  both  sides ;  in  addition  to  serious  disturbances  of  motilit}'  and 
sensibilitj'. 

38.  Localized  destruction  of  the  gray  matter  (f  the  dorsal  region  of 
the  cord  seems  to  arrest  the  control  of  the  will  over  the  reflex  acts  of 
micturition  and  defecation,  which  are  governed  by  the  lumbar  region  of 
the  cord.  These  functions  are  still  performed  with  nearly  their  normal 
regularity,  however,  by  reflex  action,  if  the  centres  that  govern  those  acts 
ai"e  not  included  in  the  diseased  area. 

39.  Scratching  or  stroking  the  skin  over  certain  regions  of  the  body 
causes  a  reflex  contraction  of  special  muscles  when  the  cord  is  healthy. 
These  are  the  so-cnlled  "  superficial  spinal  reflexes.''''     They  are  of  value 


96  LECTURES   ON    NEEVOUS    DISEASES. 

oftentimes  in  deciding  as  to  the  upper  limits  of  a  lesion.  Among  the 
more  important  of  these  superficial  reflexes  may  be  enumerated  the 
plantar,  cremasteric,  abdominal,  epioastric,  and  scapular.  Both  ceix'bral 
and  spinal  lesions  create  modifications  of  them,  which  possess  clinical 
value. 

40.  The  so-called  '' deep  spinal  reflexes'^  are  called  into  action  by 
first  putting  a  muscle  in  a  state  of  moderate  tension,  and  then  exciting  it 
to  contraction  hy  some  artificial  stimulus,  as  a  slight  tap  or  blow  for 
example.  Among  the  more  important  of  these  may  be  mentioned:  (1) 
The  knee-jerk  or  patella-reflex ;  (2)  the  foot-  or  ankle-reflex  ;  (3)  the  jser- 
oneal  or  lateral  foot-reflex.  These  tests  are  emploj'ed,  like  the  preceding 
ones,  to  determine  the  state  of  the  spinal  cord  when  the  existence  of  a 
lesion  is  suspected;  the}'  may  be  increased,  diminished,  or  abolished, 
according  to  the  character  of  the  lesion. 

41.  A  pe7'sistenf  foot-clonus  never  occurs  in  health.  It  indicates 
that  the  lateral  columns  ot  the  cord  are  probably  involved  by  some  s})inal 
lesion.  In  supposed  hysterical  affections,  this  symptom  will  often  decide 
the  question  of  the  existence  of  organic  disease.  It  must  not  be  mis- 
taken for  the  involuntary  foot-clonus  which  sometimes  occurs  when  an 
unnatural  posture  is  long  maintained,  even  in  health.  It  is  usuallv  asso- 
ciated with  exaggeration  of  all  the  other  deep  reflexes. 

42.  All  reflex  tests  become  abolished  Avlien  the  muscles  are  sepa- 
rated from  their  connection  with  the  spinal  cord  ;  hence,  severing  of  a 
nerve,  posterior  sclerosis,  compression  of  the  spinal  nerve  roots,  destruc- 
tion of  the  gray  matter  of  the  cord,  poisons,  etc.,  are  often  associated 
with  their  complete  abolition. 

43.  Disease  of  the  lateral  columns  usually  decreases  the  skin  re- 
flexes, especially  those  of  the  trunk.  This  is  particularly  true  of  the 
so-called  descending  degeneration  of  these  columns,  which  follows  cere- 
bral lesions. 

44.  When  marked  incoordination  of  movements  is  yjresent  and  the 
deep  reflexes  are  not  abolished,  it  indicates  that  sclerosis  of  the  lateral 
columns  probably  co-exists  with  similar  changes  in  Burdach's  or  Goll's 
columns. 

45.  Spasm  is  a  marked  symptom  in  many  diseases  of  the  spinal 
cord.  It  commonly  indicates  an  excessive  action  of  the  reflex  motor 
centres.  It  is  particularly  common  as  an  acute  symptom  in  spinal  me- 
ningitis. In  chronic  organic  diseases  of  the  cord,  it  assumes  the  form  of 
contracture  of  muscles,  especially  if  the  lateral  columns  are  attacked. 
This  condition  becomes  transformed  into  that  of  genuine  spasm  when  the 
slightest  forms  of  peripheral  impressions  are  experienced,  as  in  delicately' 
manipulating  the  muscles  for  exam})le. 


SUMMARY   OF    CEREBRO-SPINAL   ARCHITECTURE. 


97 


A  DIAGRAIviMATIC  SUMMARY  Qf^   SOME  OF  THE  PRINCIPAL  FEATURES 
OF   CEREBRAT    AND   SPINAL   ARCHITECTURE. 

I  have  endeavored,  as  a  sequel  to  my  previous  remarks,  to  represent 
in  a  schematic  way  the  mutual  relations  of  the  encephalic  and  spinal 
centres,  and  to  show  the  mechanism  by  which  various  phenomena  ob- 
served during  life  may  be  explained.  Let  us  examine  different  parts 
of  the  diagram  separately. 


CeKaaium 


MOTOR -OCU  LI 

AND 

Optic   Nerves 


P.C.)  Sp/nal  Cord 


Fig.  35. — A  Schematic  Representation  of  the  Cerebral  and  Spinal  Centres  and 
THEIR  Communications.  J/,  J/',  J/",  M'" ,  motor  centres;  S,  S',  S" ,  S'",  sensory 
centres;  C.  6".,  corpus  striatum  ;  O.  7!, optic  thalamus;  A.  C,  anterior  cornua  ;  P.  C,  pos- 
terior cornua.  The  arrows  indicate  the  direction  of  the  currents.  The  te.xt  will  further 
explain  the  significance  of  the  diagram. 

THE    CEREBRAL    HEMISPHERES. 

1.  The  circles  {M)  represent  the  motor  and  psi/chic  centres  of  the 
convolutions ;  the  circles  (S)  represent  the  sensory  centres  of  the  same. 
The  lines  in  the  diagram  which  connect  these  centres  with  the  basal 
ganglia  are  the  fibres  of  conduction  to  and  from  the  cells  of  the  gra}' 
matter  of  the  convolutions  (cerebral  cortex).  These  fibres  are  the  so- 
called  "peduncular,"  "  radiating,"  and  "converging"  fibres  of  different 

7 


98  LECTURES    ON   NERVOUS    DISEASES. 

authors.  Taken  as  a  wliolc,  tliey  constitute  the  so-called  "corona 
radiata." 

The  fibres  of  both  the  internal  and  external  capsule  of  the  cerebrum 
do  not  become  associated  ivith  the  cells  of  the  basal  ganglia.  They  pass 
without  interruption  from  the  cells  of  the  cerebral  cortex  to  those  of  the 
graj'  matter  of  the  spinal  cord.  Although  not  separately  shown  in  the 
diagram,  they  can  be  imagined  as  passing  over  C.  S.  and  O.  T.  in  the  cut 
as  unbroken  lines. 

The  lines  marked  (a)  represent  the  so-called  '•  associating  fibres  " 
of  the  cerebral  hemispheres. 

Throughout  the  diagram,  all  efferent  fibres,  or  those  which  carry  im- 
pulses/ro»i  the  various  centres,  are  represented  by  unbroken  lines,  and 
all  afferent  fibres,  or  those  wdiich  carry  impulses  to  the  various  centres, 
by  dotted  lines.  The  arrows  also  show  the  direction  of  the  currents. 
The  fibres  connected  with  the  centres  of  the  hemispheres  can  be  traced  in 
the  drawing  downward  to  their  union  with  the  cells  of  the  basal  ganglia, 
the  mesence})halon,  the  medulla,  and  the  spinal  cord.  In  any  of  these 
regions  separately,  or  in  all  simultaneously  the  cerebral  cortex  can  prob- 
ably exert  its  direct  influence ;  the  smaller  centres  are  then  either  over- 
powered or  controlled  in  their  respective  automatic  actions  by  the  great 
centre  of  intelligence — the  cerebrum. 

THE   BASAL    GANGLIA. 

2.  The  corpus  striatum  (C.  S.)  is  shown  to  be  associated  with  the 
motor  regions  of  the  cortex  (M).  A  direct  communication  probably  also 
exists  between  it  and  the  optic  thalamus  (0.  T.),  as  shown  by  the  line 
(b).  The  cerebellum  is  tliought  by  some  to  communicate  indirectly  with 
it  by  means  of  the  "  processus  e  cerebello  ad  cerebrum"  (4) — known  also 
as  the  "  superior  cerebellar  peduncle." 

These  three  sets  comprise  its  afferent  fibres.  Its  eff'erent  fibres  (1,2. 
and  3)  pass  to  the  cells  of  the  cms,  medulla,  and  spinal  cord.  The  con- 
nection shown  between  the  cerebellum  and  the  so-called  "  motor  tract," 
will  help  to  interpret  tlie  view  held  l)y  some  that  that  ganglion  assists  the 
cerebrum  in  its  control  over  tlie  muscular  apparatus  of  the  body. 

The  optic  tJiahunus  (0.  T.)  has  afferent  filn-es,  which  arise  from  the 
spinal  cord,  ineaulla.  .and  mesencephalon  (5,  6,  and  7),  and  from  the  cere- 
bellum (8).  It  is  thus  brought  into  relation  with  all  sensory  impulses 
conveyed  by  the  spinal  nerves,  and  also  by  those  cranial  nerves  which 
are  not  motor  in  function.  Impressions  derived  from  sight,  smell,  hearing, 
and  taste,  as  well  as  tactile  impressions,  and  the  sensation  of  pain,  are 
probably  more  or  less  intim.ately  associated  with  this  ganglion.  The 
eff'erent  fibres  of  the  optic  thalamus  are  shown  to  lie  in  the  posterior  part 
of  the  corona  radiata,  and  to  distribute  themselves  among  the  sensory 


SUMMARY   OF   CEEEBUO-SPINAL   ARCHITECTURE.  99 

centres  of  the  cerebral  cortex  (S).  The  fibres  of  direct  communication 
between  the  optic  thalamus  and  the  corpus  striatum  (6),  help  to  explain 
the  abilit}'  of  an  animal  to  perform  automatic  coordinated  movements 
lifter  the  cerebral  hemispheres  have  been  removed  and  the  basal  ganglia 
left  intact.  These  phenomena  are  in  marked  contrast  to  the  forms  of 
reaction,  which  take  place  within  the  hemispheres  betAveen  the  sensory 
and  motor  centres  of  the  cortex;  since  consciousness  and  volition  are 
evoked  b}'  the  latter,  while  the  lormer  is  purel}'  automatic.  Conscious 
appi-eciation  of  sensations  and  voluntary  motion  are  onl}-  possible  when 
the  cerebral  hemispheres  are  present. 

THE   CEREBELLUM. 

3.  This  diagram  shows,  in  an  imperfect  wa}^  the  relations  of  the 
cerebellum  to  the  paths  of  sensory  and  motor  conduction.  The  sensory 
and  motor  centres  of  this  ganglion  (S'  and  M')  have  not  been  anatomi- 
call}^  ditlerentiated  from  each  other,  but  we  have  reason  to  believe  that 
both  varieties  exist.  The  afferent  fibres  of  the  cerebellum  {9,  10,  and  11) 
probably  bring  it  into  direct  relation  with  tactile  impressions  by  means 
of  the  spinal  cord,  with  sensations  of  pain  (?)  by  the  same  channel,  and 
with  various  other  impressions  by  means  of  nerves  of  special  sense.  Its 
erterent  fibres  (^  and  12)  are  related  in  an  imperfectly  understood  way, 
to  the  path  of  motor  conduction.  The  most  delicate  feats  of  equilibrium 
are  probably  impossible  without  an  intact  cerebellum.  This  subject  will 
be  discussed  hereafter.  p]ach  hemisphere  of  the  cerebellum  is  now  be- 
lieved to  be  associated  with  the  fibres  of  the  opposite  hemisphere  of  the 
cerebrum. 

THE   MESENCEPHALON. 

4.  As  shown  in  the  diagram,  this  term  includes  all  the  parts  com- 
prised between  the  cerebrum  above  and  the  medulla  below.  The  col- 
lections of  gray  matter  represented  by  the  circles  {M")  and  (S"),  comprise 
chiefly  the  so-called  "substantia  nigra"  and  the  ''red  nucleus  of  the  teg- 
mentum." The  fibres  associated  with  them  (7,  2,  3,  4i  ^i  ^i  ^)  ^j  ^i  ^0, 
11,  and  12),  constitute,  collectively,  the  basis  and  tegmentum  C7^uris  of 
Meynert,  which  are  separated  by  the  substantia  nigra.  The  red  nucleus 
lies  beneath  the  corpora  quadrigemina  in  the  tegmentum  (the  sensor3' 
portion  of  the  crus),  and  is  in  intimate  relation  with  the  fibres  of  the 
su[)erior  cerebellar  peduncle  (4).  The  corpora  quadrigemina  (not  shown 
in  the  diagram)  should  be  also  included  among  the  ganglionic  masses  of 
this  region.  The  third  cranial  nerve  is  represented  as  structurally 
related  to  the  mesencephalon.  The  optic  nerve  has  also  intimate  rela- 
tions with  some  of  its  parts.  Fibres  of  many  of  the  cranial  nerves,  which 
spring  from  the  medulla,  arc  prolonged  through  the  pons  and  crus  to 
reach  the  cerebrum. 


100  LECTURES   ON    NEKVOUS   DISEASES. 

The  functions  of  the  mesencephalic  centres  are  too  com})lex  to 
justify  any  generalizations.  All  of  the  complex  forms  of  muscular 
activity  which  are  more  especially  elicited  in  response  to  some  form  of 
impression  received  from  without  by  means  of  the  nerves  of  special 
sense,  such  as  locomotion,  emotional  expression,  etc.,  are  to  be  attributed 
parti}',  if  not  wholly,  to  these  ganglionic  centres.  The  special  attributes 
of  the  red  nucleus  of  the  tegmentum  and  the  substantia  nigra  are,  as  yet, 
somewhat  conjectural. 

THE   MEDULLA   OBLONGATA. 

r>.  Within  this  ganglion,  the  nuclei  of  origin  of  many  of  the  cranial 
nerves  have  been  found,  and  special  centres  which  preside  over  important 
ph^'siological  functions  have  also  been  demonstrated.  The  circles  (J/'") 
and  [S'^')  in  the  diagram  are  supposed  to  represent  the  sensory  and  motor 
collections  of  gray  matter,  which  give  to  this  portion  of  the  central 
nervous  system  its  peculiar  powers.  The  motor  centres  {31")  are  repre- 
sented as  in  communication  with  certain  cranial  nerve  roots,  and  also 
with  motor  fibres  which  serve  to  connect  the  medulla  to  the  corpus 
striatum  and  the  ganglionic  masses  of  the  mesencephalon  above,  and  the 
segments  of  the  spinal  cord  below.  The  sensory  centres  (S'")  are  shown 
to  be  in  relation  with  the  sensory  cranial  nerve  roots  (the  term  "sensory  ' 
being  used  in  its  broadest  sense  to  include  all  fibres  bearing  aSerent 
impulses),  as  well  as  with  the  paths  of  cerebral  and  cerebellar  sensory 
conduction  {6  and  10).  Thus  it  is  that  the  cerebellum  as  well  as  the 
cerebrum  probably  is  made  cognizant  not  only  of  tactile  sensations  and 
of  other  varieties  of  sensory  impulses  transmitted  along  the  spinal  tracts, 
but  also  of  other  facts  which  our  special  senses  reveal  to  us.  The  view 
that  the  cerebellum  acts  in  part  as  an  "■  informing  depot "  (Spitzka)  for  the 
cerebral  hemispheres  can  be  comprehended  by  a  stud}'  of  this  diagram. 

The  fibres  which  are  drawn  in  the  diagram  between  the  motor  and 
sensory  centres  of  the  medulla  help  us  to  comprehend  the  probable 
mechanism  of  many  forms  of  complex  coordinated  reflex  actions,  of 
which  the  medulla  is  capable  when  all  the  nerve  centres  above  it  have 
been  removed.  It  is  apparent  that  each  of  the  segments  of  the  nervous 
system  here  depicted  is  capable  (by  means  of  associating  fibres)  of  an 
action  of  its  own  which  is  independent  of  those  centres  above  it,  but 
which  may  be  controlled  or  overpowered  by  the  higher  centres  when  they 
are  called  into  action. 

THE   SPINAL   COED. 

(3.  The  diagram  shows  the  cells  of  the  anterior  horns  of  the  spinal 
gray  matter  (A.  G.)  to  be  in  connection  with  the  fibres  of  the  direct  motor 
tract  which  we  have  now  traced  from  the  cerebral  cortex  downward 
(although  some  have  been  deflected  from  the  direct  path  by  the  cells  of  the 


SUMMARY   OF    CEREBRO-SPINAL   ARCHITECTURE.  101 

mesencephalon  and  medulla).  These  motor  tihres  of  the  spinal  cord  are 
prolonged  by  means  of  the  interposed  cell  (A.C.)  as  fibres  of  the  anterior 
or  motor  roots  of  the  spinal  nerves.  The  cells  of  the  p(jsterior  horns 
of  the  spinal  ixmy  mat'^er  (F.  C.)  are  likewise  shown  to  receive  the  afferent 
impulses  conveyed  to  them  from  without  by  the  posterior  or  sensory 
roots  of  the  spinal  nerves  (as  shown  by  the  arrow),  and  to  transmit  them 
upward  by  means  of  fibres  which  connect  them  with  higher  ganglionic 
masses  (J,  6',  and  7).  The  exact  paths  of  motor  and  sensory  conduction 
through  the  spinal  cord  are  not  positively  settled.  The  antero-lateral 
columns  of  the  cord  are  connnonly  regarded  as  tlie  chief  motor  paths, 
although  all  observers  are  not  in  agreement  respecting  the  anterior 
columns.  The  sensory  tracts  probably  run  partly  in  the  central  gra}' 
matter  of  the  cord,  and  partly  in  the  lateral  and  posterior  columns.  Sen-- 
sory  impulses  travel  on  the  side  opposite  to  that  on  which  the  nerves 
enter,  with  the  exception  of  impressions  of  the  so-called  muscular  sense 
(Starr).  The  views  held  respecting  the  functions  of  the  spinal  columns 
have  been  given  in  preceding  pages. 

Finally,  it  will  be  observed  that  the  motor  and  sensory  cells  of  the 
spinal  cord  communicate.  This  arrangement  nllows  of  an  automatic 
spinal  action.  Beheaclcd  animals  can  be  made  to  exhibit  definite  mus- 
cular movements  wiien  any  irritation  of  the  sensory  nerves  of  the  skin 
is  employed  to  call  them  forth.  A  frog  so  mutilated  will  scratch  with 
the  opposite  foot  a  spot  on  the  leg  which  has  been  touched  with  an  acid. 
Robin  has  observed  similar  phenomena  in  a  beheaded  criminal.  These 
movements  are  purely  reflex  in  type,  because  all  parts  w^hich  we  know  to 
be  essential  to  consciousness  or  volition  have  been  taken  away.  They 
can  only  be  attributed,  therefore,  to  a  communication  (not  yet  well  un- 
derstood) between  the  sensory  and  motor  cells  of  the  spinal  segment. 
Many  of  the  acts  which  constant  and  long-continued  practice  enable  us 
acquire  during  life — as,  for  example,  the  running  of  scales  upon  a  piano 
— are  unquestionably  performed  automatically  by  the  spinal  cord,  with- 
out assistance  of  the  higher  ganglia  in  many  instances. 

In  closing  this  section,  the  Author  feels  that  much  has  of  necessity 
been  omitted;  and  that  some  of  the  views  advanced  are  apt  to  be 
modified  or  possibly  overthrown  by  subsequent  investigation. 

He  trusts,  how^ever,  that  the  ditticulties  of  the  task  will  not  be  lost 
sight  of  1)}'  the  reader ;  and  that  the  chapter,  as  a  whole,  may  prove  of 
material  assistance  in  fathoming  the  mysteries  of  obscure  neuroses. 

The  two  diagrams  which  follow  are  copied  from  Aeby.  They  {)re- 
sent,  to  the  Author's  mind,  the  main  points  in  cerebro-spinal  architecture 
with  singular  lucidity. 


102 


LECTURES   OX   NERVOUS  DISEASES. 


Fig.  o6. 


•iGs.  36  and  ST. — A  Diagram  of  the  Course  of  the  Nerve  Fibres  in  the  Substance 
op  THE  Brain  and  Spinal  Coru.  (AfterAeby.)  I,  view  of  a  transverse  section  ;  II,  Pro- 
file view;  III,  the  nuclei  of  the  medulla  (partly  after  Erb).  The  crosses  of  color  corre- 
sponding to  the  lines  upon  which  thej'  are  placed,  designate  the  point  of  section  of  each  tract 
as  it  passes  through  different  levels  (the  crus  and  pons).  C  i,  internal  capsule,  with 
radiating  fibres  (in  yellow),  pyramidal  fibres  (red),  and  fibres  going  to  the  pons  (in  purple): 
P  C,  the  crura  cerehri,  with  the  pyramidal  fibres  and  the  fibres  going  to  the  gnnglia  of  the 
pons  anteriorly,  and  posteriorly,  the  .substantia  nigra,  the  fillet  tract  (in  dotted  lines),  the 
fibres  of  the  superior  peduncle  of  the  cerebellum  (in  blue) ;  Pc,  the  peduncles  of  the  cere- 
helltivi,  showing  the  fibres  going  to  the  cerebrum,  the  pons,  and  the  medulla:  P,  pom 
I'arolii,  with  its  ganglia  on  either  side  (in  purple).  In  III.  the  nuclei  of  the  cranial  ncrTC 
roots  are  numbered  to  correspond  with  the  nerves.     Red  is  used  for  the  motor  nuclei,  and 


SUMMARY   OF   CERERRO-SPINAL   AKCHITECTURE. 


103 


Fig.  87. 


I 


blue  for  the  sensory  nuclei.  The  tracts  in  the  cord  are  designated  by  the  area  similarly 
colored  in  the  cross-section  of  the  cord  beneath,  c',  Column  of  Tiirck  ;  c.  crossed  pyramidal 
column;  a,  anterior  horn;  a',  anterior  root  zone:  e,  direct  cerebellar  column;  b,  posterior 
horn;  b',  column  of  Burdach ;  d,  column  of  Goll.  Higher  up  are  seen  b",  the  inferior 
peduncle  of  the  cerebellum;  d',  the  fillet  or  lemniscus  tract;  f,  the  fibres  connecting  the 
ganglia  of  the  pons  with  the  cerebrum  and  cerebellum ,  b'",  the  fibres  of  the  superior  cere- 
bellar peduncle ;  h,  the  caudo-lenticular  and  thalmo-cortical  fibres;  i,  the  commissural  fibres 
(see  Fig.  6);  Th,  optic  thalamus;  nc,  nucleus,  caudatus;  nl,  nucleus  lenticularis ;  gc,  central 
convolutions. 

In  this  diagram,  the  course  of  b"  seems  to  be  in  error  in  not  undergoing  a  decussation 
(Author's  note). 


SECTION  II. 


PRACTICAL    HINTS    EEGARDING   THE    CLINICAL 

EXAMINATION   OF   PATIENTS   AFFLICTED 

WITH  NERVOUS  DISEASES,  AND  THE 

VARIOUS  TESTS  WHICH  MAY 

BE  EMPLOYED  AS  AIDS 

IN  DIAGNOSIS. 


SECTION  II. 

THE   METHODS   OF    EXAMINATION   EMPLOYED   IN    THE  DIAGNOSIS   OF 

NERVOUS   DISEASES. 

The  majoritAT^  of  practitioners  apparently  join  in  the  feeling  (which 
happily  conduces  largely  to  the  benefit  of  specialists  in  neurology)  that 
nervous  anatomy  and  phj^siology  is  "too  complex  a  subject  for  them  to 
master,"  and  that  they  must  be,  therefore,  given  over  to  those  who  are 
devoting  themselves  particularly  to  the  department  of  nervous  diseases. 

While  this  may  be  true  in  part,  I  believe  that  it  is  not  only  possible 
but  comparatiA^ely  easy  for  any  medical  practitioner  (who  is  willing  to 
make  the  necessary  effort)  to  grasp  certain  general  principles  which  are 
applicable  to  the  examination  of  cases  afflicted  with  nervous  diseases. 

These  can  be  applied  without  expensive  apparatus,  and  with  decided 
benefit  both  to  himself  and  his  patients.  They  will  tend  to  render  his 
diagnosis  more  scientific  and  accurate.  They  will  aid  him  in  properly 
directing  his  treatment.  Finally,  they  will  often  save  him  the  humiliation 
of  seeing  his  patient  seek  advice  from  other  hands. 

The  intelligence  of  laymen  is  always  strongly  impressed  by  evidences 
on  the  part  of  the  physician  of  great  care  and  marked  skill,  as  shown  in 
the  first  examination.  The  impressions  left  upon  the  patient's  mind  by 
the  results  of  the  first  interview  are  of  the  greatest  importance  to  both 
parties.  While  the  doctor  is  studying  the  patient,  the  patient  is,  as  a 
rule,  stud3ang  the  doctor  with  even  greater  interest. 

Every  step  which  is  talien  by  the  physician,  as  a  means  of  forming  a 
positive  and  final  judgment,  is  watched  with  an  earnestness  on  the  part 
of  the  patient  that  invariably  accompanies  mental  anxiety.  Each  ques- 
tion that  is  asked  regarding  the  previous  history  of  the  patient,  the  pos- 
sibility of  similar  troubles  in  his  parents  or  blood-relations,  the  origin 
and  course  of  the  more  important  sjmptoms,  etc.,  are  even  more  indelibly 
impressed  upon  the  mind  of  the  patient  than  upon  that  of  the  physician, 
who  keeps  the  written  record. 

When,  later  in  the  examination,  the  power  or  electrical  reactions  of 
the  muscles,  and  the  sensibility  of  different  regions  of  the  body  to  touch, 
temperature,  and  pain  are  being  tested  in  various  ways,  and  the  results 
of  such  tests  are  being  recorded  in  the  case-book  of  the  physician,  the 
reasoning  faculties  of  the  patient  are  even  more  keenly  alive,  and  seek  to 
penetrate  (as  far  as  his  intelligence  will  permit  him  to  do)  into  the  mys- 
teries of  the  science,  and  to   draw  conclusions    regarding  the   clinical 

(107) 


108  LECTUEES   ON   NERVOUS  DISEASES. 

significance  of  ccrtnin  sym]itojns,  of  wliich,  perhaps,  he  was  unconscious 
up  to  tliat  time.  It  will  often  be  necessary,  therefore,  for  the  pliysician  to 
quiet  evidences  of  alarm  on  the  part  of  the  patient,  from  time  to  time,  as 
the  examination  of  the  symptoms  proceed,  by  judicious  explanation  or 
words  of  encouragement. 

It  should  ever  be  remembered  by  the  ph3'sician  that  any  omission 
on  his  part  to  investigate  the  condition  of  the  motor  or  sensory  nerves, 
the  pulse,  the  respiration,  the  temperature,  the  spinal  reflexes,  etc.,  in 
each  and  every  case,  will  sooner  or  later  be  remarked  by  some  patient, 
who  has  either  read  extensively  or  had,  from  time  to  time,  diflerent 
medical  advisers.  Moreover,  interested  friends  (sometimes  very  intelli- 
gent from  past  experiences  of  their  own)  may  often  drop  hints  to  the 
patient  which  will  tend  to  strengthen  or  weaken  his  or  her  views  that 
have  previously  been  formed  of  the  accuracy  and  care  of  the  first  exami- 
nation of  the  symptoms. 

It  is  my  intention  to  give  here,  with  some  detail,  the  description  of 
the  various  steps  that  are  commonly  employed  by  specialists  in  neurology 
in  the  examination  of  their  patients  ;  and  to  suggest  a  simple  method  of 
recording  symptoms,  as  a  basis  for  the  diagnosis  and  subsequent  treat- 
ment of  nervous  affections, 

I  shall  discuss  the  subject  under  the  following  heads: — 

First. — The  clinical  histor}^  of  the  patient,  and  how  to  record  the 
chief  symptoms  of  each  case. 

Second. — The  symptoms  revealed  to  the  phj'sician  by  his  sense  of 
sight. 

Third. — The  symptoms  revealed  to  the  physician  b3^  instruments  of 
various  kinds,  and  other  tests, 

I. 

THE   CLINICAL   HISTOEY   OF   THE  PATIENT, 

Every  physician  should  be  provided  with  a  case-book.  In  it  the 
main  features  of  each  patient's  case  should  be  first  recorded,  and  a  memo- 
randum of  the  treatment  and  modifications  of  the  symptoms  should  be 
subsequently  jotted  down  at  each  visit.  In  this  way  only  can  the  results 
of  an  extended  experience  be  made  useful  for  scientific  purposes  at  some 
later  date.  It  will  furthermore  aid  the  doctor  in  utilizing  his  leisure 
hours  b}"-  studying  the  cases  which  he  meets  during  the  bus3'  routine  of 
his  office  work.  One  case  well  studied  is  worth  a  hundred  casuall}' 
glanced  at  and  hastily  prescribed  for. 

It  will  help  to  economize  time  if  the  case-book  is  printed  in  such  a 
way  as  to  have  the  more  important  symptoms  already  upon  the  page; 
spaces  being  left  blank  to  allow  of  a  record  of  any  modifications  of  these 


THE   CLINICAL   HISTORY   OF   THE   PATIENT.  109 

tlmt  may  exist.  This  plan  adds  to  the  legibility  of  the  notes,  and  also 
admirably  adapts  them  for  comparison  with  those  of  previous  or  subse- 
quent cases.  Each  physician  may  alter  the  arrangement  of  the  pages  of 
his  case-book  to  suit  his  individual  practice,  but  it  is  best  for  a  general 
practitioner  to  have  it  adapted  for  all  classes  of  patients. 

In  a  subsequent  portion  of  this  chapter  I  will  suggest  a  form  of  case- 
book which  seems  to  me  to  be  well  adapted  to  the  requirements  of  a 
specialist  in  nervous  diseases. 

Let  us  now  suppose  that  a  patient  enters  the  office  of  a  physician  for 
medical  advice  relating  to  a  nervous  malad}'.  After  the  usual  questions 
have  been  asked  the  patient  regarding  the  name,  the  age,  the  condition 
as  to  marriage,  the  nationality,  and  the  occupation,  and  the  answers 
recorded,  the  patient  should  be  brought  rapidly  to  a  concise  statement  of 
the  more  important  symptoms  for  which  he  seeks  medical  relief.  This 
can  be  usually  accomplished  by  a  little  tact ;  and  much  valuable  time  is 
saved  by  so  doing.  These  S3'mptoms  can  then  be  separately  recorded 
upon  a  page  in  your  case-book. 

With  these  especially  marked  S3'mptoms  as  a  starting-point,  ques- 
tions may  then  be  asked  regarding  certain  of  them  which  the  physician 
deems  the  most  important  from  a  clinical  aspect;  seeking  in  each  instance 
to  learn  all  about  the  present  and  past  history  of  one  sr/mjjtom  at  a  timey 
and  the  modifications  which  have  been  observed  concerning  it,  so  far  a& 
the  patient's  memory  will  prove  of  assistance. 

Now,  the  ability  on  the  part  of  the  doctor  to  ask  questions  that  are 
pertinent  to  each  symptom  will  depend  entirely  upon  the  knowledge 
which  he  himself  possesses  of  the  subject.  I  have  often  tested  medical 
students  and  young  practitioners  in  this  regard,  and  have  been  amused 
to  see  how  rapidly  their  stock  of  pertinent  inquiries  became  exhausted. 

In  order  to  intelligently  ask  about  pain,  for  example,  the  physician 
must  know  all  the  axioms  of  nerve-distribution  which  Hilton  so  ably 
advanced  ;  he  must  be  a  master,  in  the  second  place,  of  the  course  of 
separate  nerves  which  enable  definite  regions  to  tell  the  doctor  (by 
the  presence  of  the  sense  of  pain)  of  disease  that  is  sometimes  far  re- 
mote from  the  painful  area;  again,  he  must  be  able  to  correctly  trace 
the  course  of  affected  nerves,  and  thus  to  seek  for  abnormal  condi- 
tions along  the  line  of  each  nerve  which  might  produce  local  pressure 
upon  them;  he  must  be  familiar,  in  the  fourth  place,  with  the  individual . 
peculiarities  of  pain  in  special  diseases,  as,  for  example,  the  characteristic 
pains  of  rheumatism,  neuralgia,  locomotor  ataxia,  etc. ;  finally,  he  must 
be  familiar  with  all  the  possible  causes  of  pain  in  different  regions  of  the 
body  or  extremities. 

When  we  shall  have  discussed  the  A'arious  symptoms  revealed  by 
inspection  of  the  patient,  as  well  as  the  tests  employed  to  determine  ab- 


110  LECTUKER   ON  NERVOUS   DISEASED. 

normal  states  of  the  motor  or  sensory  nerves,  and  tlie  reactions  of  muscles 
to  different  electric  currents,  many  points  will  have  been  given  that  may 
prove  of  assistance  in  suggesting  pertinent  questions,  to  be  employed  in 
obtaining  the  clinical  history  of  patients  so  afflicted;  but  it  will  require 
continued  practice,  much  study,  and  close  observation  to  excel  in  the  art 
of  quickly  and  accurately  gathering  pertinent  fiicts,  from  which  con- 
clusions can  be  drawn  regarding  the  diagnosis  and  treatment  of  r.ervous 
diseases. 

A  few  general  hints  may,  however,  be  thrown  out  here  as  to  special 
lines  of  inquiry,  each  of  which  may  afford  us  valuable  information  re- 
specting nervous  maladies. 

The  Duration  of  Existing  Symptoms. — It  is  important  to  ascertain 
the  exact  date  of  the  commencement  of  the  symptoms  for  which  the 
patient  seeks  relief,  or  of  others  which  may  be  detected  by  the  physician 
at  the  first  interview. 

This  will  often  decide  as  to  the  acuteness  of  the  attack,  and  also 
afford  in  some  instances  information  respecting  the  seat  and  type  of  the 
disease. 

In  the  chronic  varieties  of  spinal  disease  (as,  for  example,  progressive 
muscular  atrophy,  locomotor  ataxia,  disseminated  sclerosis,  etc.),  the 
patient  cannot,  as  a  rule,  fix  the  date  at  which  the  symptoms  commenced 
because  the  development  has  been  extremely  slow  and  gradual. 

On  the  other  hand,  a  hysterical  fit  ma}'  be  followed  immediatel}'  by 
an  attack  of  hysterical  paralysis ;  a  hemorrhage  into  the  brain  or  spinal 
cord,  that  has  ploughed  up  the  substance  of  these  organs,  causes  paralytic 
symptoms  that  develop  instantly;  inflammatory  changes  of  the  brain  or 
cord  are  usuall}'  attended  by  a  more  gradual  onset,  although  it  may  be 
comparatively  rapid. 

As  an  illustration  of  the  clinical  bearing  of  the  duration  of  symptoms, 
let  us  take  the  following:  Two  patients  present  a  deformed  hand  from 
atrophy  of  the  muscles  of  the  thumb  and  interossei.  The  one  has  been 
slowly  developed,  and  is  probably  the  result  of  progressive  muscular 
atrophy;  the  other  has  been  very  rapidly  developed,  and  is  probabl}-  due 
to  some  disease  or  local  injury  of  the  ulnar  nerve.  Should  the  deformity 
have  occurred  in  years  past,  and  have  shown  no  evidences  of  steady  pro- 
gression, the  existence  of  progressive  muscular  atrophy  could  be  then 
safely  excluded. 

The  Exciting  Cause  of  Existing  Symptoms. — If  there  has  been  nwy 
external  violence  received,  it  is  important  to  ascertain  the  exact  nature, 
seat,  and  severity  of  the  injury. 

Concussion  of  the  spine  may  cause  severe  and  often  fatal  disease  of 
the  spinal  cord.  Violence  to  the  head  may  depress  the  inner  tablet  of  the 
skull  without  any  evidence  of  depression  upon  the  exterior.     The  brain 


THE   CLINICAL   HISTOKY   OF   THE   PATIENT.  Ill 

may  be  seriously  injured,  when  the  bones  that  encase  it  may  escape. 
Some  of  the  spinal  nerves  may  be  implicated  in  a  wound  or  bruise,  and 
thus  paralysis  may  be  induced  independently  of  the  nerve  centres. 

Mental  anxiety  or  overwork  is  a  frequent  cause  of  brain  diseases. 
Eye-defect  acts  very  frequently  as  an  etiological  factor  in  many  cases  of 
headache,  neuralgia,  hysteria,  epilepsy,  chorea,  and  some  obscure  visceral 
derangements.  Some  defects  in  the  eye  are  inherited  (as  are  peculiarities 
in  feature  and  mental  traits).  This  field  will  be  discussed  later  in  this 
chapter. 

A  family  tendency  to  gout  or  rheumatism,  etc.,  may  suggest  the 
possibility  of  an  abnormal  blood-condition  as  an  important  factor  in 
creating  nervous  disturbances. 

The  urine  should  always  be  carefully  examined,  as  well  as  the  heart, 
to  exclude  the  possibility  of  renal  or  cardiac  disease  as  a  factor  in  the 
nervous  derangement. 

The  Age  of  the  Patient. — Much  may  be  suggested  to  the  mind  of 
the  physician  by  the  age  of  the  patient;  because  some  diseases  are 
more  common  at  one  period  of  life  than  at  another. 

During  early  childhood  we  are  particularly  liable  to  encounter  the 
symptoms  of  idiocy,  epilepsy,  and  chorea,  as  well  as  those  of  an  inflam- 
mation of  the  anterior  horns  of  the  gray  matter  of  the  spinal  cord,  the  so- 
called  "  poliom^'elitis  anterior."  The  acute  variet}^  of  the  latter  disease  is 
most  common  between  the  ages  of  one  and  four,  and  it  is  seldom  devel- 
oped except  in  childhood.  In  the  vast  majority  of  cases,  the  condition 
termed  "pseudo-hypertrophic  paralysis  "  (because  the  muscles  are  over- 
grown like  those  of  an  athlete)  is  developed  during  the  first  few  years  of 
life.  Again,  the  tubercular  form  of  inflammation  of  the  meninges,  both 
of  the  brain  and  spinal  cord,  occur  in  the  young  child.  Among  the  rarer 
forms  of  disease  of  the  spinal  cord,  a  congenital  variety  of  the  so-called 
"spastic  paralysis,"  and  also  of  "locomotor  ataxia,"  is  encountered  in 
3'oung  children.  Reflex  paraplegia  is  also  occasionally  seen  in  very 
young  subjects.  Cases  of  disseminated  sclerosis  of  the  spinal  cord  have 
been  reported  in  the  child. 

Between  the  ages  of  puberty  and  the  fully  developed  adult,  Pott's 
disease  of  the  vertebra  may  develop  and  create  compression  of  the  spinal 
cord;  and  attacks  of  rheumatism  may  render  the  development  of  embolic 
hemiplegia  and  aphasia  possible.  Meningitis  of  the  brain  and  spinal 
cord  are  not  uncommon  during  this  interval.  Hysterical  paraplegia 
occurs  in  young  females  in  connection  with  uterine  disturbances.  Be- 
tween the  ages  of  twenty  and  thirty,  cerebro-spinal  sclerosis  is  most 
commonly  developed. 

In  the  adult,  yjrogressive  muscular  atrophy,  m3'elitis,  meningitis  of 
the  cord,  locomotor  ataxia,  the  chronic  form  of  poliomyelitis,  and  amyo- 


112  LECTUKES   ON   NERVOUS  DISEASES. 

trophic  lateral  paralysis  are  amonir  the  spinal  diseases  often  encountered. 
Cerebral  mcninijjitis,  and  soflcninii-,  tumors,  and  embolism  of  the  brain 
are  freciuently  recognized.  Sliaking  palsy  seldom  occurs  except  in  ad- 
vanced life.  Tlie  symptoms  of  Duchenne's  disease,  and  the  paral^-sis  of  the 
insane  are  most  commonly  developed  between  the  ages  of  thirty  and  sixt,y. 

Linked  with  adult  life,  also,  comes  apoplexy  associated  with  paralysis ; 
and  a  late  rigidity  of  the  paral^'zed  muscles  is  developed  whenever  the  in- 
jury excites  a  descending  degeneration  of  the  fibres  that  are  torn  across  by 
escaping  blood,  or  deprives  the  cerebrum  of  its  power  of  control  over  the 
cerebellum.  Excessive  indulgence  in  eating  and  drinking,  coupled  with 
the  absence  of  proper  phj'sical  exercise,  and  the  possibility  of  acquired 
s^'philis,  render  males  more  subject  to  paralysis  than  females. 

The  Sex. — Males  suffier  much  more  frequentlj^  from  organic  nervous 
affections  than  females. 

This  fact  is  to  be  accounted  for  partly  by  the  liability  of  that  sex  to 
injury,  exposure  to  cold  or  dampness,  and  excessive  mental  or  physical 
labor.  But  habits  of  indulgence  in  alcohol  and  venery,  with  its  danger 
of  syphilitic  infection,  are  also  far  more  common  in  males  than  in  females, 
and  are  often  prominent  factors  in  the  causation  of  morbid  conditions  of 
the  nerve  centres.  Certain  occupations,  tending  toward  great  muscular 
strain,  or  lead,  arsenic,  and  mercurial  poisoning,  may  be  exciting  causes 
of  serious  nervous  affections.  Prolonged  exposure  to  compressed  air  (as 
in  the  case  of  divers)  is  often  followed  by  paralysis.  Many  such  cases 
have  occurred  among  workmen  in  submarine  excavations. 

The  Heredity. — After  you  have  exhausted  the  special  lines  of 
inquiry  indicated  bv  the  prominent  S3'mptoms  that  each  patient  seeks 
relief  for,  questions  should  then  be  propounded  to  the  patient  touching 
upon  the  possibility  of  hereditary  predisposition  to  nervous  affections 
or  of  some  hereditary  "diathesis."' 

Some  nervous  affections  exhibit  a  marked  dependence  upon  a  heredi- 
tary predisposition,  either  to  the  disease  actually  pi'esent,  or  to  some 
allied  disorder.  Epileptics,  for  example,  are  frequently  the  offspring  of 
tubercular  or  syphilitic  parents,  or  of  epileptics.  Again,  choi-ea  and 
hysteria  may  be  developed  from  the  most  trivial  excitement  (even  from 
imitation  of  others  so  affected)  in  subjects  predisposed  to  nervous  ex- 
citability or  debility.  Apoplectic  sul)jects  not  infrequently  beget  off- 
spring who  manifest  in  adult  life  a  decided  tendencj'  to  vascular  disease. 
Certain  spinal  affections  seem  to  be  particularly  associated  with  heredity. 
A  predisposition  to  cancer  and  tuberculosis  is  unquestionably  transmitted, 
and  these  conditions  are  not  infrequently  found  in  the  brain  and  spinal 
cord,  or  their  envelopes. 

A  marked  hereditary  tendency  toward  some  spinal  affections  seems 
to  be  well    established.     Pseudo-h^-pertrophic    paralysis    is  transmitted 


THE   CLINICAL   HISTORY   OF   THE   PATIENT.  113 

through  the  mother.  Locomotor  ataxia  occasionally  runs  in  families,  and 
progressive  muscular  atropli}'  is  markedly  hereditary.  Quite  a  large  pro- 
portion of  h3'sterical  women  can  be  shown  to  have  sprung  from  ancestry 
in  which  tuberculosis,  epilepsy,  or  insanity  has  existed ;  and  idiotic 
children  and  epileptics  sometimes  owe  their  disease  to  a  so-called  "  hys- 
terical temperament"  on  the  mother's  side.  I  believe  that,  in  many  cases, 
this  predisposition  can  be  traced  to  an  inherited  defect  in  the  ocular 
muscles,  or  a  refractive  error  in  the  eye  itself,  which  creates  eye-strain 
when  binocular  vision  is  attempted.  This  view  is  based  upon  an  exami- 
nation of  quite  a  large  number  of  such  cases. 

Habits  op  the  Patient. — These  should  be  the  next  subjects  of 
inquiry. 

Alcoholic  subjects  are  always  surrounded  by  dangerous  possibilities. 
Inflammation,  when  once  started  in  such  patients,  is  liable  to  be  of  a 
severe  and  fatal  form.  Trivial  injuries  often  excite  serious  complications 
in  such  subjects,  and  hereditary  or  acquired  diseases,  which  have  been 
comparatively  dormant  for  some  time,  may  be  kindled  into  activity  by  a 
"spree." 

Again  the  habitual  use  of  drugs  for  nervousness,  sleeplessness,  and  all 
the  other  ailments  with  which  the  laity  often  experiment  at  the  suggestion 
of  friends,  but  without  the  knowledge  of  their  doctor,  may  be  a  factor  in 
nervous  symptoms  that  have  become  aggravated  or  actually  developed 
by  their  injudicious  use.  Some  patients  can  use  tobacco  without  ap- 
parent injury,  while  it  is  a  rank  poison  to  others  ;  tea  and  coflee  are  like- 
wise injurious  to  many  patients.  The  long-continued  use  of  chloral,  the 
bromides,  opium,  or  other  drugs  may  result  in  nervous  affections  of  a 
serious  character. 

The  Occupation  of  the  Patient. — This  may  be  a  possible  factor 
in  the  development  of  nervous  diseases. 

Sewing-girls  frequently  develop  ulceration  of  the  stomach  from  the 
pressure  exerted  upon  that  organ  by  stooping.  Painters  are  peculiarly 
liable  to  lead-poisoning;  and  in  some  arts,  where  mercurial,  phosphoric, 
and  arsenical  preparations  are  extensively  employed,  symptoms  of  these 
forms  of  poisoning  may  be  developed.  Constant  or  prolonged  exposure 
to  cold  or  dampness  is  veiy  often  an  exciting  cause  of  spinal  affections. 
Excessive  exercise  or  occupations  demanding  an  unusual  strain  upon  the 
muscles  may  induce  actual  disease  of  the  muscles,  peripheral  nerves, 
spinal  cord,  or  brain.  Extreme  mental  labor  or  anxiety  is  a  frequent 
cause  of  brain  inflammation  and  changes  within  the  coats  of  the  blood- 
vessels of  that  organ. 

The  Acquired  Diseases. — Einally,  the  previous  history  of  the 
patient  in  respect  to  acquired  diseases  is  especially  important  as  an  aid 
in  deciding  as  to  the  probable  cause  of  the  existing  symptoms. 

8 


114  LECTURES     ON     NERVOUS     DISEASES. 

All  attacks  of  illness  which  have  been  passed  through  should  be 
carefull}^  inquired  into. 

The  presence  or  absence  of  latent  sypliilis  should  always  be  investi- 
gated as  perhaps  one  of  the  most  coninioii  causes  of  nervous  allections. 
Tlie  presence  or  absence  of  tubercular  deposits  in  the  lungs,  or  of  cancer 
in  the  breast  or  viscera,  should  be  decided  b}'  a  physical  examination, 
because  similar  deposits  may  exist  elsewhere  in  the  body.  Some  of  the 
fevers  often  cause  sequehe  that  create  impairment  of  the  senses  of  sight 
and  hearing,  as  well  as  other  nervous  phenomena.  Cerebro-spinal  men- 
ingitis may  leave  after-ertects  upon  the  nerve  centres  that  last  for  an  in- 
delinite  period.  Kidney  diseases  may  result  in  serious  changes  in  the 
blood-vessels,  and  thus  be  a  factor  in  the  development  of  brain  troubles. 
Diphtheria  is  frequently  followed  b}-  paralj'sis  of  the  throat  and  limbs. 
Diabetes  may  itself  indicate  an  existing  brain  disease ;  or,  as  the  result 
of  imperfect  performance  of  the  digestive  processes,  create,  in  turn, 
S3"mptoms  referable  to  the  nervous  mechanism.  In  point  of  fact,  few,  if 
any  of  the  more  common  diseases  are  entirely  exempt  from  a  more  or 
less  direct  association  with  nervous  phenomena. 

There  is  a  prevalent  opinion  among  the  lait^*  (and  unfortunate!}', 
with  some  of  the  profession  also)  that  the  nervous  system  is  a  distinct 
and  separate  part  of  the  human  organization;  an  entity  entirely  inde- 
pendent of  the  otlier  organs  and  having  functions  peculiarly'  its  own. 
They  seem  to  forget  tliat  it  is  nourished  by  tlie  same  source  as  muscle, 
bone,  organs,  etc.,  e.g.,  tlie  blood  ;  also  tliat  every  part  of  the  body  is 
capable  of  sending  telegraphic  communications  to  the  brain  and  spinal 
cord  by  means  of  the  sensory  nerves;  and,  finally,  that  these  organs 
are  called  into  action  rather  as  the  servants  of  the  other  parts  of  tlie 
body  than  as  independent  organisms,  by  the  various  impressions  which 
they  receive  from  without.  All  the  mental  processes  are  based,  of  necessity 
upon  some  impressions  of  the  outer  world  gained  by  means  of  the  organs 
of  sight,  smell,  hearing,  touch,  taste,  or  the  nerves  of  general  sensibility. 

The  apparent  disassociation  which  exists  between  the  nervous  cen- 
tres and  the  viscera  often  misleads  the  practitioner  of  medicine,  and 
causes  him  to  disregard  the  importance  of  a  complete  examination  of  the 
various  organs  before  a  final  judgment  is  expressed  concerning  nervous 
phenomena  that  are  brought  to  his  notice. 

Some  of  tlie  moie  common  forms  of  nervous  affections  are  purel}' 
functional.  Text-boolvs  abound  in  cases  where  some  disease  of  the  intes- 
tine, ovaries,  uterus,  kidneys,  bladder  and  uretlira  have  been  the  exciting- 
cause  of  paralysis,  and  of  serious  effects  upon  the  nerve  centres.  The 
eye  is  also  a  very  frequent  factor  in  functional  nervous  diseases — although 
the  fact  is  not  generally  recognized  by  authors.  This  field  will  be  dis- 
cussed later.     Hysteria  is  often  associated  with  an  attack  of  paralysis 


THE   CLINICAL   HISTORY   OF   THE   PATIENT.  115 

that  is  not  easily  ditfercntiated  from  the  types  of  paralysis  produced  by 
destructive  processes  within  the  brain  and  spinal  cord.  Epilejjsy  and 
St.  Vitus' dance  are  purely  nervous  diseases,  and  yet  they  may  sometimes 
be  the  indirect  result  of  a  defective  assimilatiou  of  food,  general  de- 
bility, some  poverty  of  the  blood,  and  many  other  causes  that  are  not 
directly  associated  with  the  nervous  system  proper. 

On  the  other  hand,  diseased  conditious  of  the  nervous  centres  may 
induce  so-called  trophic  changes,  or  changes  of  nutrition,  not  only  in  the 
muscles — as  is  evidenced  by  atrophy  of  a  more  or  less  complete  kind — 
but  also  in  the  skin,  the  various  organs,  the  joints,  and  even  in  the  bones. 

The  peripheral  nerves  preside,  not  only  over  the  muscles  to  which 
they  give  the  power  of  contraction,  and  the  tactile  organs  of  the  skin,  to 
which  they  contribute  the  ability  to  perceive  all  varieties  of  impressions, 
such  as  the  tactile  sense,  the  sense  of  cold  and  of  heat,  the  feelings  of 
pain,  etc.,  but  they  have  another  equally  important  function,  which  they 
exercise  chiefly  by  means  of  the  so-called  vaso-motor  filaments,  viz.,  the 
regulation  of  the  blood  supply  to  the  viscera,  organs  of  special  sense, 
muscles,  bones,  joints,  and  skin.  Now,  when  the  nerve  centres  become 
involved  by  any  form  of  destructive  process  that  cuts  off  these  so-called 
"trophic  fibres"  from  connection  with  certain  parts  of  the  spinal  cord  or 
brain,  definite  regions  of  the  body  may  waste  away  without  exhibiting 
pnralysis,  the  eye  and  ear  may  lose  their  marvelous  functions,  and  the 
skin  may  develop  different  forms  of  eruptions,  bed-sores,  etc. 

Finally,  the  spinal  cord  and  the  medulla  oblongata  (which  is  its 
uppermost  portion)  contain  certain  collections  of  nerve  cells  or  "reflex 
centres  "  that  preside  over  the  more  important  functions,  or  those  essen- 
tial to  life. 

By  means  of  an  excitability  which  is  present  in  these  collections  of 
cells,  the  heart  is  kept  pulsating;  the  res]nrations  go  on,  even  in  spite  of 
any  voluntary  efforts  made  to  arrest  them;  the  pupil  dilates  and  con- 
tracts when  exposed  to  different  degrees  of  light;  and  the  bladder  and 
rectum  expel  the  excretions  that  accumulate  within  them.  In  the  same 
way  the  sexual  act  is  rendered  possible  in  the  male;  the  stomach  and 
intestine  keep  up  a  perpetual  worm-like  movement;  swallowing  is  per- 
formed in  such  a  way  that  the  food  does  not  enter  the  air-passages  or  pass 
upward  into  the  nose;  the  calibre  of  the  blood-vessels  is  constantly  altered, 
so  as  to  meet  the  demands  of  different  parts  of  the  body  when  active  or 
at  rest;  and  the  acts  of  vomiting,  hiccough,  sneezing,  sighing,  laughing, 
etc.,  are  rendered  possible,  and  often  involuntar}-. 

In  closing  this  section  of  the  chapter,  I  take  the  liberty  of  presenting 
a  sample  page  of  m\'  own  case-book,  specially  designed  for  the  recording 
of  the  results  of  the  first  examination  of  jiatients  afflicted  with  any  form 
of  nervous  malady.     Some  of  the  headings  will  be  discussed  in  subsequent 


116 


LECTURES   ON   NERVOUS   DISEASES. 


pa_2;cs.  Their  bearings  upon  diagnosis  will  then  be  made  clear.  The 
page  whicli  laces  the  i)rintcd  one  is  left  blank  to  allow  of  subsequent 
record  of  the  treatment  and  any  new  symptoms  that  mny  arise. 


Name Age. 

Hereditary  tendencies  : 

Parents 

Brothers  and  sisters 

Near  relatives 

Clinical  history  : 
Acquired  diseases — 

Fevers 

Lungs 

Kidneys 

Pelvic  organs 

Venereal 

Habits,  as  to  diet 

"  "     alcohol 

"  "     tobacco  or  drugs 

"  "     venery 

Motor  phenovietia 


Sensoyy  pheno7nena. 
Attitude 


Gait. 


Sense  of  smell. 


Eye  : 

Pupils 

Lids 

Ocular  movements... 

Vision 

Condition  of  fundus. . 

£ar  : 

Deformities 

Hearing 


.Occupation Date. 

Mouth  : 
Taste 

Articulation 

Deglutition , 

Attitude  of  lips , 

Movements  of  tongue 

Brain  : 

Memory , 

Emotions 

Logical  powers 

Sleep 

Aphasia 

Vertigo 

Spinal  cord  : 

Supei  ficial  reflexes 

Deep  refle.ves 

Delayed  sensation 

Anaesthesia 

Hy  peraisthesia 

Pain 

Co-ordination 

Pulse 

Temperature 

Respiration 

Voice 

Tremor 

Fibrillary  twitchings 

Handwriting 

Condition  of  arteries 

of  urethra 

of  bladder 

of  uterus 

of  ovaries 

of  urine 

of  heart 

Diagnosis  and  Remarks. 


II. 

SYMPTOMS   OF   NERVOUS   DISEASES   REVEALED    TO   THE   PHYSICIAN 
BY    HIS   SENSE   OF   SIGHT. 

When  a  patient  and  his  medical  adviser  meet  for  the  first  time  there 
are  many  medical  facts  which  may  be  detected  simply  by  a  glance,  with- 
out a  question  being  asked.  Sorhetimes  information  thus  gained  is  in- 
valuable to  the  doctor,  and  of  the  greatest  importance  in  diagnosis.  To 
become  skillful  in  this  line,  however,  both  study  and  practice  are  requisite. 


SYMPTOMS   EEVEALED   BY  THE   SENSE   OF   SIGHT.  117 

Some  years  since  I  published,  in  the  New  York  Medical  Journal^  a 
contribution  to  tiie  study  of  medical  physiognomy  which  has  been 
honored  by  two  foreign  translations;  and,  in  my  late  work  on  "Medical 
Anatomy"  (Wood's  Library  for  1882),  I  have  devoted  an  entire  chapter 
to  the  subject.  In  this  article,  however,  I  shall  only  touch  upon  such 
23oints  as  are  related  to  the  diagnosis  of  nervous  diseases. 

This  section  of  my  article  I  shall  discuss  under  the  following  heads: 
1,  The  study  of  the  features  and  general  appearance  of  the  patient.  2, 
The  study  of  the  gait  and  the  attitude  of  the  patient,  when  sitting,  stand- 
ing, or  reclining. 

The  Features  and  General  Appearance  op  the  Patient. — 
One  glance  at  a  face  affected  with  such  striking  alterations  as  those 
produced  by  Bell's  paralysis,  Uuchenne's  palsy  in  its  advanced  state, 
marked  atrophy  of  the  facial  muscles,  and  some  other  nervous  conditions 
which  are  associated  with  extreme  facial  deformity,  would  be  sufficient 
with  even  an  inexperienced  practitioner  for  a  diagnosis.  But  all  diseases 
of  the  nervous  centres,  or  of  the  cranial  nerves  themselves,  independently 
of  the  brain,  are  not  so  forcibly  evidenced  in  the  face.  Something  of  value 
can,  however,  usually  be  learned  by  a  careful  study  of  each  of  its  parts, 
especially  the  forehead,  ej-e,  lips,  tongue,  and  ear.  It  has  been  my  custom 
for  some  years  to  have  impressions  from  untouched  photographic  nega- 
tives made  of  man}-  of  my  patients  before  any  mode  of  treatment  was 
commenced.  I  have  found  them  very  useful  in  many  wa3's;  and  they 
certainly  constitute  the  easiest  and  most  reliable  method  of  recording 
some  medical  facts. 

A  prominent  and  tortuous  artery  upon  the  temple  may  catch  the 
eyQ  of  the  doctor.  It  is  well  to  know  that  such  a  condition  often  accom- 
panies kidney  disease. 

A  scanning  of  the  face  will  show  whether  the  complexion  is  ruddy, 
as  in  health,  or  pale  from  some  cachexia;  clear  and  free  from  eruptions, 
or  sallowed  and  dingy;  waxy  and  transparent,  as  in  Bright's  disease,  or 
tinged  with  blue  from  imperfect  ox3'genation  of  the  blood. 

In  children,  certain  lines  or  wrinkles  may  possiblj^  exist  that  point 
strongly  to  some  complicating  disease  of  the  brain,  lungs,  heart  or 
digestive  organs,  the  presence  of  persistent  pain,  and  other  valuable  data. 
In  adults,  or  the  aged,  these  lines  are  of  less  clinical  importance.  I  have 
discussed  them  in  other  articles,  previousl}'  referred  to. 

A  collar  loosened  or  open  ma}^  suggest  some  difficulty  in  breathing. 
An  untied  shoe  may  cover  a  dropsical  foot ;  a  slit  in  the  region  of  the 
"great-toe"  joint  may  have  been  made  as  a  relief  to  gout}^  inflammation; 
one  shoe  badly  worn  at  the  toe  ma}'  tell  of  an  existing  hemiplegia.  Pa- 
tients  with  enfeebled  mental  powers  and  drunkards  are  particularly  liable 
to  have  their  clothing  wrongly  or  incompletely  buttoned ;  the  pants  im- 


118  LECTURES   ON   NERVOUS   DISEASES. 

perfectly  closed  or  open ;  the  shoe  down  at  the  heel ;  the  hair  uncombed, 
and  to  present  other  evidences  of  indifference  to  neatness  of  appearance. 

Good,  strong  hair  in  abundance,  and  teeth  that  are  free  from  defects, 
are  evidences  in  the  adult  of  a  naturally  vigorous  constitution.  Broad 
shoulders  and  deep  chests  are  lilcewise  an  indication  of  inherited  strength 
both  of  the  organs  and  muscles. 

The  Diathesis. — The  general  appearance  of  the  patient  may  afford 
some  valuable  information  respecting  an  hereditarj^  diathesis.  Laycock 
has  admirably  described  them. 

Patients  of  the  "f/o»f//"  dinfhesis  usually  have  a  heavy  frame,  well- 
developed  muscles,  a  large  head  and  jaw,  strong  hair  and  teeth,  a  robust 
appearance,  and  an  erect  carriage.  They  are  peculiai-ly  susceptible,  in 
adult  life,  to  diseases  of  the  blood-vessels,  apoplexy,  aneurism,  and  heart 
troubles. 

In  contrast  to  this  type,  those  of  the  well-marked  ^^ strumous^^  dia- 
theais  have  a  light,  bony  framework,  which  is  often  characterized  by  an 
enlargement  of  the  ends  of  the  long  bones.  The  hand  is  sometimes  un- 
shai:)ely  from  this  peculiar  defect,  or  the  rings  which  will  pass  the  joints 
are  too  large  for  "the  finger.  The  chest  of  such  subjects  is  also  small. 
The  glands  of  the  neck  tend  to  become  enlarged  at  about  the  age  of 
pubert3^ 

The  hair  of  strumous  subjects  is  apt  to  lie  thin  and  fine.  The  eye- 
lashes are  usually  long  and  silken,  although  the  lids  may  sometimes  be 
diseased  and  the  lashes  more  or  less  disfigured.  As  children,  they 
are  liable  to  be  unusually  precocious.  The  teeth  are  crowded  into  a 
narrow  arch  and  are  liable  to  decay  earlv.  The  under  jaw  is  light.  Evi- 
dences of  rickets  in  childhood  may  exist  during  adult  life.  Scrofulous 
children  inherit  "eitiier  a  velvety  skin,  dark-brown  complexion,  dark  hair, 
dark  brilliant  eyes  and  long  lashes,  Avitli  the  lineaments  of  a  face  finely 
drawn  and  expressive;  or  a  fair  complexion,  thick  and  swollen  nose, 
broad  chin,  teeth  irregular  and  developed  late,  inflammation  of  the  Mei- 
bomian glands,  scrofulous  ophthalmia,  eruptions  of  the  head,  nose,  and 
lips,  and  enlarged  cervical  glands."  These  subjects  are  often  "chicken- 
breasted"  and  "bow-legged."  The  "  strumous  diathesis"  entails  a  pecu- 
liar liabilit}^  to  defective  nutrition,  glandular  enlargements,  and  "con- 
sumptive" changes  Avitliin  the  lungs  during  early  manhood.  Epilepsy 
and  hydrocephalus  often  develop  in  such  subjects  during  infancy  or 
childliood. 

The  so-called  '■'■  nervo^is''''  diathesis  is  commonly  associated  with  small 
but  perfect  bones,  an  absence  of  fat,  a  well-formed  cranium,  small  features, 
quick  intelligence,  and  an  active  frame.  They  usuallj^  have  a  bright  eye 
and  small  abdominal  organs.  They  bear  fatigue  well,  but  are  peculiarly 
susceptible  to  nervous  excitability  and  depression.     In  adult  life  they 


SYMPTOMS   REVEALED   BY   THE   SENSE   OF   SIGHT.  119 

become  the  more  common  victims  to  neuralgia,  epilepsy,  hysteria,  dipso- 
mania, and  many  other  nervous  diseases. 

Dark-haired  and  swarthy  subjects  are  often  of  the  so-called  "6i7zoi^s" 
temperament.  They  commonly  possess  large  frames,  strong  muscles,  and 
a  tendency  to  moderate  obesity.  They  are  active  rather  than  lethargic. 
The  digestive  organs  are  often  disturbed  by  habits  of  over-indulgence  at 
the  table  or  excessive  mental  efforts.  Such  subjects  commonly  suffer 
from  "sick-headaches"  from  early  childhood,  and  often  develop  gouty 
symptoms  in  early  adult  life.  They  are  not  infrequently  victims  to  vas- 
cular changes,  kidney  disease,  and  apoplexy,  after  the  age  of  fifty  years. 

The  '■'■lymphatic^'  diathesis  is  generally  met  with  in  sluggish,  lazy, 
and  large  subjects.  They  are  commonly  addicted  to  alcohol  (because 
they  suffer  from  fatigue)  and  to  excessive  eating.  They  have  heavy 
bones,  but  soft  and  flabby  muscles.  They  are  often  pale.  They  usually 
thrive  best  in  invigorating  climates. 

Now,  it  must  be  remembered  that  it  is  seldom  that  the  physician 
meets  either  of  these  types  unadulterated.  A  man  of  the  gouty  diathesis, 
with  a  wife  of  the  "nervous"  type,  will  probably  have  children  that  ex- 
hibit certain  characteristics  of  both.  Hence  it  is  ofteil  desirable,  before 
making  a  diagnosis,  to  inquire  into  the  peculiarities  of  build  and  tem- 
perament of  the  ancestors  of  patients  afflicted  with  nervous  diseases,  as 
well  as  to  their  duration  of  life  and  the  causes  of  their  death. 

The  Cachexia. — These  are  diseased  conditions,  Tlie  ones  which 
are  most  frequently  recognized  by  the  neurologist  are  those  of  syphilis, 
cancer,  gout,  mercurial  or  lead-poisoning,  and  malaria.  In  all  of  these 
tliere  is  poverty  of  the  blood,  because  the  red  corpuscles  are  more  or  less 
destroyed  and  the  constituents  of  the  blood-plasma  are  altered.  If  a 
cachexia  is  superimposed  upon  some  special  form  of  diathesis,  a  double 
danger  to  the  patient  is  the  result.  A  strumous  subject,  for  example, 
may  have  his  tubercular  tendencies  materially  hastened,  if  not  actually 
developed,  by  malaria,  syphilis,  and  mercurial  or  lead-poisoning. 

Special  Physiognomy. — As  the  physician  scans  the  features  of  his 
patient,  it  is  best  to  inspect  different  parts  of  the  face  separately,  as  it 
were.     Let  us  note  what  he  should  particular!}^  observe. 

The  Forehead. — If  the  forehead  be  well  dcA^eloped,  the  "nervous 
diathesis"  is  liable  to  be  present.  If  protuberant  and  overhanging  a 
small  and  imperfectly-developed  face,  rickets,  hereditary  syphilis,  or 
hydrocephalus  have  probably  existed  in  childhood.  If  hereditary 
syphilis  has  conduced  toward  the  cranial  deformity,  the  teeth  will  be 
found  to  be  defective.  Ulceration  upon  the  forehead,  unless  it  be  due  to 
a  wound,  is  invariably  syphilitic.  Scars  of  this  region  or  copper-colored 
spots  are  equally  significant  and  suggestive.  Depressed  fractures  over 
the  frontal  region  are  not  necessaril}^  associated  in  the  adult  with  injury 


120  LECTURES   ON  NERVOUS   DISEASES. 

to  the  brain,  even  if  extensive,  because  the  frontal  sinuses  are  devel- 
oped after  pul)erty,  and  the  front  wall  of  the  sinus  may  be  then  crushed 
in  without  disturbing  the  back  wall  or  the  underlying  brain.  A  very 
small  cranium  and  a  retreating  forehead  are  often  present  in  imbeciles. 

Tlie  Eye. — In  the  aged,  if  the  cornea  be  cloudy,  you  should  lift  the 
upper  ej'elid  and  seek  for  an  arc  of  a  lighter  shade — the  so-called  "  areas 
senilis." 

If  it  exist,  and  its  edges  are  indistinctly  defined,  there  is  reason  to 
suspect  that  the  tissues  of  the  bod}^  (especially  the  heart)  are  under- 
going fatty  degeneration. 

The  pupils  should  be  examined  to  see  if  they  are  equal  in  size,  and 
if  their  movements  are  in  any  way  impaired. 

There  is  one  condition,  called  from  its  discoverer  the  '■'■  Robertson 
pupil,"  that  is  of  the  greatest  significance  to  the  neurologist,  because  it 
indicates  a  hardening,  or  "  sclerosis,"  as  it  is  called,  of  the  spinal  cord.  It 
occurs  only  when  this  disease  has  involved  the  "cilio-spinal  centre"  of 
the  cord.  This  condition  is  indicated  in  the  eye  by  preternaturally  small 
pupils  that  do  not  respond  to  light,  but  which  still  move  when  efforts  to 
accommodate  the  vision  to  near  objects  (i.e.,  within  a  radius  of  twent}'' 
feet)  are  demanded. 

To  test  this  fact,  place  the  patient  at  a  window  and  instruct  him  to 
look  fixedly  at  some  object  more  than  twentv  feet  off'  whenever  his  eyes 
are  open,  so  that  the  pupil  need  not  contract  in  order  to  focus  the  vision. 
Now  tell  him  to  close  the  eyes  and  keep  them  closed  until  instructed  to 
open  them.  After  sufficient  time  has  elapsed  for  the  pupils  to  have  be- 
come dilated,  tell  him  to  open  his  eyes.  Watch  carefully  at  this  moment 
for  a  response  in  the  pupils,  as  they  will  contract  instantly  in  health.  If 
they  fail  to  do  so,  the  existence  of  spinal  sclerosis  is  almost  positively 
indicated. 

Abnormalities  of  the  pupils  ma}^  afl'ord  the  practitioner  material  aid 
in  diagnosis. 

The  pupils  are  found  to  be  dilated  during  attacks  of  dj'spnoea  and 
after  excessive  muscular  exertion,  in  the  later  stages  of  anjesthesia,  and 
in  cases  of  poisoning  from  belladonna  and  other  drugs  of  similar  action. 
A  contracted  state  of  the  pupils  exists  during  alcoholic  excitement,  in  the 
early  stages  of  anagsthesia  from  chloroform,  and  in  poisoning  by  morphia 
or  other  preparations  of  opium,  ph^'sostigmine,  chloral,  and  some  other 
drugs.  Paralysis  of  the  third  cranial  nerve  creates  a  dilated  condition 
of  the  pupil  of  the  same  side,  since  that  nerve  controls  the  circular  fibres 
of  the  iris. 

Again,  one  pupil  may  dilate  irregularly'  in  a  weak  light.  This  sug- 
gests the  existence  of  adhesions  of  the  iris,  as  a  result  of  past  inflamma- 
tion.    Iritis   is    often   syphilitic,   and   this  symptom   may  tell   of  past 


SYMPTOMS   REVEALED   BY   THE   SENSE   OF   SIGHT.  121 

infection.    Tlie  inner  surface  of  the  eyelid  is  a  valuable  guide  to  detect  the 
presence  of  ans^mia,  as  it  shows  a  pallor  that  is  in  marked  contrast  to  the 
redness  of  health.     Alcoholic  subjects  are  apt  to  have  a  vascular  redness  , 
of  the  eyeball.     Bright's  disease  often  causes  a  drop  of  fluid  beneath  th(/) 
conjunctiA'a  that  might  be  mistaken  for  a  tear.     It  can  be  moved,  how- 
ever, while  a  tear  cannot  witliout  causing  its  disappeai'ance. 

In  connection  with  hemianopsia  (see  previous  section)  there  may  be 
an  absence  of  pupillary  movement  upon  one  lateral  half  of  each  eye — 
the  so-called  "  hemiopic  pupillary  reaction." 

The  movements  of  the  eye  should  be  a  subject  of  special  inquiry. 
Brain  diseases  sometimes  manifest  their  existence  very  early  by  some 
form  of  paralysis  of  the  ocular  muscles.  Strabismus  or  cross-eye  may 
exist  when  the  third  or  sixth  cranial  nerves  are  impaired.  We  meet  it 
chiefly  in  connection  with  hydrocephalus,  apoplectic  clots,  brain-tumors, 
cerebral  meningitis,  growths  within  the  orbit,  and  as  a  congenital  or  ac- 
quired deformit3\     This  subject  will  be  fully  discussed  later. 

It  is  a  fact  well  known  among  oculists,  and  one  which  often  helps 
them  materially  in  diagnosis,  that  the  defects  of  vision  occasioned  by  a 
serious  impairment  in  the  power  of  some  of  the  muscles  which  control 
the  e3^eball,  cause  the  patients  unconsciousl}^  to  assume  an  abnormal 
position  of  the  head,  which  tends  to  assist  them  in  the  use  of  the  aflected 
eye.  So  diagnostic  are  some  of  the  attitudes  assumed  by  this  class  of 
afflicted  people,  that  the  condition  which  exists  may  be  told  at  a  glance, 
as  the  patient  enters  a  room,  by  one  thoroughly  familiar  with  diseases 
of  this  important  organ.  The  explanation  of  this  tendency  on  the 
part  of  this  class  of  patients  lies  in  the  fact  that  a  loss  of  power  in  the 
ocular  muscles  may  immediately  show  itself  in  the  perception  of  every 
object,  as  it  were  doubled;  and  it  is  to  overcome  these  double  images 
that  patients  almost  instantaneously  discover  their  ability  to  get  rid  of 
the  annoyance  by  some  special  attitude,  which,  of  course,  depends  upon 
the  muscle  that  is  weakened  or  paralyzed. 

It  will  be  necessary,  in  order  to  clearly  understand  the  mechanism 
of  this  peculiarity,  that  the  separate  action  of  the  six  muscles  which 
directly  act  upon  the  globe  of  the  eye  be  considered. 

The  action  of  each  of  the  ocular  muscles  may  be  given,  then,  as  fol- 
lows, with  the  proviso  that  many  of  the  motions  of  the  eye  are  not  the 
result  of  the  contraction  of  any  single  muscle,  but  often  of  a  number 
acting  either  in  unison  or  successively. 

The  superior  oblique  muscle  turns  the  eye  downward  and  outward; 
the  inferior  oblique  muscle  turns  the  eye  upward  and  outward;  the 
superior  rectus  muscle  turns  the  eye  downward  and  inward;  the  internal 
rectus  muscle  turns  the  eye  directly  inward;  the  external  rectus  muscle 
turns  the  eye  directly  outward. 


122  LECTURES   ON   NERVOUS   DISEASES. 

This  statement  as  to  the  above  muscles  reveals  nothing  which  would 
not  be  immediately'  suggested  by  the  insertion  of  each,  with  the  excei)tion 
of  the  superior  and  inferior  recti  muscles,  which,  besides  the  action  that 
their  situation  would  naturally  suggest,  tend  also  to  draw  the  e3feball 
inward,  on  account  of  the  oblic^uity  of  the  axis  of  the  orbit,  and  the  same 
obliquit}'  of  the  muscles,  since  they  arise  at  the  apex  of  the  orbit.  The 
action  of  the  oblique  muscles  is,  as  any  one  familiar  with  their  origin 
and  insertion  would  naturally  surmise,  to  control  the  oblique  movements 
of  the  eyeball. 

/Now,  as  soon  as  any  one  of  these  six  muscles  becomes  pressed  upon 
and  weakened  by  the  presence  of  tumors,  inflammatory,  exudation, 
syphilis,  or  other  causes,  the  patient  at  once  perceives  double  images, 
/^  and,  in  order  to  get  his  eye  into  such  a  relative  position  with  that  of  the 
healthy  side  as  to  enable  them  both  to  focus  upon  the  same  object  in  a 
natural  manner,  the  patient  soon  learns  to  so  move  his  head  as  to  compel 
the  two  eyes  to  look  in  parallel  directions. 

A  very  simple  rule  can  be  suggested  by  which  the  ph3-sician  may  be 

enabled  not  only  to  tell  in  what  direction  a  patient  would  move  his  head 

I        in  case  any  special  muscle  be  rendered  weak  or  utterly  useless,  but  also  to 

\       diagnose  the  muscle  aflected,  when  he  looks  at  the  patient,  without  an}- 

knowledge  of  his  history.    The  rule  may  be  thus  stated  :  In  j)aresis  of  any 

of  the  ocular  muscles,  the  head  is  so  dejiected  from  its  normal  joosition  that 

the  chin  is  carried  in  a  direction  corresponding  to  the  action  of  the  af- 

(  ■  fected  muscle. 

\  Thus,  in  paresis  of  the  external  rectus,*  the  chin  would  be  carried 

outward  toward  the  attected  muscle ;  while  in  paresis  of  the  internal 
rectus  muscle  the  head  would  be  turned  away  from  the  side  on  which  the 
muscle  fails  to  act.  In  case  the  superior  oblique  muscle  is  impaired,  the 
chin  would  be  carried  downward  and  outward ;  while  in  case  of  the  inferior 
oblique  muscle,  the  chin  would  have  to  be  moved  upward  and  outward  to 
benefit  the  vision  of  the  patient.  The  superior  and  inferior  recti  muscles, 
when  impaired  by  disease  or  other  causes,  would  likewise  create  a  de- 
flection of  the  head  in  a  line  corresponding  to  that  of  their  respective 
actions. 

Paresis  of  the  external  and  internal  recti  muscles  occasionally  causes, 
in  addition  to  the  facts  already  described,  another  point  of  verj^  great 
value  in  diagnosis,  viz.,  an  alteration  in  the  apparent  size  of  the  objects 
seen    fi'om    what   they  would   be   in    health.     The   condition   of  vision 

*  While  this  statement  would  be  absolutely  true  in  theory  in  all  cases,  we  must  ac- 
knowledge, as  a  clinical  fact,  that  patients  learn  to  utterly  disregard  the  image  in  the 
aflected  eye  when  the  internal  or  external  rectus  is  the  seat  of  paresis,  and  to  use  the 
normal  eye  only  for  the  purposes  of  vision,  thus  rendering  this  attitude  of  the  head  less 
diagnostic  than  when  the  oblique  muscles  are  affected. 


THE  EYE  AS   A  WHOLE.  123 

termed  by  oculists  "  megalopsia,"  or  "micropsia,"  often  signifies  paresis 
of  the  external  rectus;  while  the  opi)osite  condition,  called  "■  mici-opsia," 
may  indicate  a  loss  of  power  in  the  internal  rectus  muscle. 

In  the  former  of  these  conditions,  the  objects  seen  by  the  patient 
seem  to  be  greater  in  point  of  size  than  the  intelligence  of  the  patient 
assures  him  is  the  case;  while  in  the  latter,  objects  seem  smaller  to  the 
patient  than  they  really  are. 

THE  EYE   AS   A   WHOLE. 

I  take  the  liberty  of  inserting,  in  this  connection,  an  extract  respect- 
ing the  eye  from  my  brochure  on  medical  physiognomy : — 

The  intimate  communications  between  the  fifth,  the  seventh,  and 
the  sympathetic  nerves,  through  the  media  of  the  ciliar}^,  otitic,  and 
Meckel's  ganglia,  would  lead  us  to  expect  that  the  eye  should  exhibit  in 
its  altered  appearance  the  derangement  of  internal  structures.  "  When  a 
glance  of  this  organ  is  caught,  what  a  field  of  mute  expression  is  open  to 
the  mind!  This  silent  or  instructive  index  of  the  whole  man  may  be 
bright  or  dull,  heavy  or  clear,  half-shut,  or  unnaturally  open,  sunken  or 
protruded,  fixed  or  oscillating,  straight  or  distorted,  staring  or  twinkling, 
fier}-  or  lethargic,  anxious  or  distressed;  again,  it  may  be  watery  or  dry, 
of  a  pale  blue,  or  its  white  turned  to  yellow." 

The  pupils  may  be  contracted  or  widely  dilated,  insensible  to  or 
intolerant  of  light,  oscillating  or  otherwise,  unequal  in  size,  or  changed 
from  their  natural  clearness  of  outline.  "Tlie  noble  arch  of  the  brow 
speaks  its  varied  language  in  every  face  of  suffering  humanity.  It  may 
be  overhanging  or  corrugated,  raised  or  depressed;  wliile  the  lid  of  the 
eye,  an  important  part  of  this  vault,  exhibits  alternations  of  puffiness  or 
hollowness,  of  smoothness  or  unevenness,  of  darkness  or  paleness,  of 
sallowness  or  brown  discoloration,  of  white  or  purple.  Lines  intersect 
this  region,  and  the  varied  tints  are  perpetually  giving  new  color,  new 
feature,  new  expression,  by  their  shadows."  If  the  frontal  muscle  acts  in 
connection  with  the  corrugator  supercilii,  an  acute  deflection  upward  is 
given  to  the  inner  part  of  the  eyebrow,  very  diflferent  from  the  general 
action  of  the  muscle,  and  decidedly  expressiA'e  of  debilitating  pain,  or  of 
discontent,  according  to  the  prevailing  cast  of  the  rest  of  the  countenance. 
An  irregularity  of  the  pupils  of  the  two  eyes  indicates,  as  a  rule,  pressure 
upon  nerve  centres  or  upon  the  optic  nerve  itself.  In  adj-namic  fevers 
the  eyes  are  heavy  and  extremely  sluggish,  and  are,  as  a  rule,  partially 
covered  by  the  drooping  eyelid;  while  in  certain  forms  of  mania  they 
are  seldom  motionless.  This  latter  peculiarity  is  also  often  noticed  in 
idiocy. 

In  tlie  so-called  "Bell's  paralysis,"  due  to  failure  of  the  facial  nerve, 
the  eyelids  stand  wide  open,  and  cannot  be  voluntarily  closed,  since 


124  LECTUKES   ON   NERVOUS   DISEASES. 

the  orbicularis  palpebrarum  muscle  is  paralyzed.  This  condition  may  be 
further  recognized,  if  unilateral,  l)y  a  smoothness  of  the  aftected  side, 
since  the  antagonistic  muscles  tend  to  draw  the  face  toward  the  side 
opposite  to  the  one  in  which  the  muscular  movement  is  impaired  ;  an 
inability  to  place  the  mouth  in  the  position  of  whistling,  because  for  this 
act  the  two  sides  of  the  face  must  act  in  unison  ;  loss  of  control  of  saliva, 
which  dribbles  from  the  corner  of  the  mouth  ;  and  a  tendency  to  accumu- 
lation of  food  in  the  cheek  since  the  buccinator  muscle  no  longer  acts. 

AVhen  the  third  pair  of  nerves  are  affected  upon  either  side,  the  upper 
eyelid  cannot  be  voluntarily  raised,  for  the  levator  palpebrae  muscle  fails 
to  act;  and  the  ej'C  is  caused  to  diverge  outward,  because  the  external 
rectus  muscle,  not  being  supplied  by  the  third  pair  and  having  no  counter- 
balancing muscle,  draws  the  eye  from  its  line  of  parallelism  with  its 
fellow.  In  photophobia,  attempts  to  open  the  eye  create  resistance  on 
the  part  of  the  patient,  since  the  entrance  of  light  causes  pain;  while,  as 
death  approaches,  or  in  the  state  of  coma  (save  in  a  feAV  exceptions),  the 
eyes  are  usuall}'  open.  In  cardiac  hypertrophy,  an  unusual  brillianc}'  of 
the  eye  is  perceived,  since  the  arterial  system  is  overfilled  from  the 
additional  power  of  the  heart.  A  peculiar  glistening  stare  exists  during 
the  course  of  scarlet  fever,  which  is  in  mariied  contrast  with  the  liquid, 
tender,  and  watery  eye  of  measles.  Man}'  diseases  of  the  eye  itself  tend 
to  greatly'  alter  the  normal  expression  of  the  face.  Prominentl>'  among 
these  may  be  mentioned  cataract,  glaucoma,  cancer,  staphyloma,  exoi> 
thalmus,  iritis,  conjunctivitis,  amaurosis,  etc.,  but  the  special  peculiarities 
of  each  need  not  be  here  described. 

THE   EYE   AS   A   FACTOR   IN   THE   CAUSATION   OF    SOME   COMMON 
NERVOUS   SYMPTOMS. 

Although  something  has  been  written  within  the  past  few  j^ears  in 
relation  to  the  deleterious  effects  of  errors  of  refraction  and  accommoda- 
tion of  vision  and  the  condition  known  as  "muscular  insufficiency"  upon 
the  functions  of  the  nervous  system  and  the  viscera,*  tlie  profession  at 

*  Priority  in  this  field  (save  in  respect  to  ocular  defect  as  a  cause  of  headache,  which 
has  been  recognized  in  a  somewhat  imperfect  way  for  many  years)  is  justly  claimed,  as  far 
as  I  know,  by  Dr.  George  T.  Stevens  of  New  York.  Although  his  views  have  been  regarded  by 
some  as  extreme  and  untenable,  those  who  have  carefully  and  accurately  investigated  the 
eyes  of  nervous  subjects  cannot,  I  think,  deny  that  defects  in  refraction  and  accommoda- 
tion, and  insufficiency  of  the  ocular  muscles,  are  very  important  and  generallj-  neglected 
factors  of  causation.  Authors  cannot  afford  to-day  to  utterly  discard  all  mention  of  the 
tests  for  muscular  insufficiency  from  neurological  works,  as  they  have  done  in  the  past. 
In  point  of  fact,  even  the  tests  for  errors  in  refraction  are  not  described  in  the  standard 
works  on  nervous  maladies.  Most  authors  seem  to  have  been  content  with  showing  a  cut 
of  some  ophthalmoscope  and  dismissing  the  subject  with  a  few  lines.  It  is  safe  to  infer 
that  such  writers  are  cith.er  not  familiar  with  the  field  here  discussed,  or  not  in  the  habit 
of  employing  the  tests  herein  described  upon  their  patients.  I  am  sure  (if  this  is  not  the 
ease)  they  could  not  remain  so  apathetic  and  apparently  inditl'ereut  to  the  results  obtained. 


THE   EYE   AS   A   FACTOR   IN   NERVOUS   SYMPTOMS.  125 

large  is  not  3'et  thoroughly  awakened  to  the  importance  of  the  detection 
and  correction  of  such  errors.  I  deem  it  of  the  greatest  importance, 
therefore,  to  call  attention  to  it  again  in  this  connection,  and  to  give  a 
full  description  of  the  testing  of  vision  and  of  the  eye  muscles. 

Most  of  you  know  that  some  persons  can  be  made  dizz}'  by  looking 
from  a  height  or  inspecting  a  water-fall;  you  have  doubtless  seen  laymen 
suffer  pains  in  the  head  and  be  made  "  sick  at  the  stomach  "  by  trying  on 
a  pair  of  spectacles  which  gave  relief  to  a  friend.*  You  doulitless  know 
that  a  "squint"  in  the  eyes  is  very  often  due  to  some  defect  in  the  refrac- 
tion of  the  eye  or  a  weakness  of  its  muscles;  but  possibly  some  of  you  do 
not  know  that  a  squint  will  occasionally  disappear  at  once  when  the 
proper  glasses  are  given  to  such  a  patient,  without  recourse  to  cutting 
the  muscle.  Perhaps  it  has  never  occurred  to  most  of  you  that  sight  is 
the  onhj  special  .nense  ivhich  tve  use  constantly  except  during  the  hours  of 
sleep.  Tliere  is  not  a  moment  of  the  day  or  evening  when  we  are  not 
accpiiring  visual  impressions  of  some  kind. 


\Z  \M 


Fig.  3S. — Diagram  to  Illustrate  Congenital  or  Acquired  Defects  in  the  Antero- 
posterior Diameter  of  the  Eye. — The  black  line,  E,  represents  the  norvial line  oi\\\\i 
eye  ;  H,  represents  the  hypermetropic  eye  :  M,  the  myopic  eye. 

Fortunately  for  our  nervous  system,  the  normal  eye  takes  pictures  of 
surrounding  objects  without  any  muscular  effort  when  the  object  is  more 
than  twenty  feet  away;  hence,  during  the  larger  part  of  each  day,  the 
normal  eye  is  passive,  and  is  practically  at  rest,  although  performing  its 
functions.  How  different  is  the  condition  of  the  far-sighted  or  "hyper- 
metropic" eye,  however,  from  the  normal!  For  this  eye  (since  it  is  too 
short  in  its  antero-posterior  axis)  all  objects  have  to  be  focused  by  mus- 
cular effort,  irrespective  of  their  distance  from  the  eye.  Such  an  eye  is 
never  passive.  It  has  no  rest  while  the  body  is  awake.  It  is  always 
straining  more  or  less  intensely  to  bring  properly  upon  tlic  retina  the 
images  of  objects  seen. 

*  Let  a  healthy  child  try  on  its  grandfather's  t;pectaeles  and  wear  them  for  a  time,  and 
the  effects  of^^eye-f!traiii"  will  be  very  clearly  exhibited  by  distressing  symptoms  in  affiw 
minutes. 


126  LECTIIKES    (1N   NERVOUS   DISEASES. 


THE   HYrEKMETROPK;    EYE. 

Tlie  "  liypcrmetro])ic  "  condition  of  the  eye,  or  "lur-siohtedness,"  as 
it  is  called,  is  a  very  common  defect.  It  is  especially  frequent  in  persons 
of  tiilHM'cular  parontace.*  It  is  well,  tliorofore,  to  sns])or't  the  existence 
of  this  defect  in  children  or  adults  whose  ancestors  hnve  died  of  "con- 
sumption." 

Il^'permetropia  cannot  lie  corrected  too  early  in  life.  It  is  imquestion- 
aV)lv  one  of  the  vmst  frequent  causes  of  '■'sick-headache,^^  whi(;h,  as  j'oii 
know,  runs  in  families.  It  is  commonly  encountered  also  (among  other 
optical  defects)  in  sulijects  afilicted  Avitli  chorea  and  epilepsy. -I*  It  is  a 
congenital  defect,  and  will  never  be  "  outgrown. "|  as  many  people  think. 
A  hypermetropic  child,  from  the  days  of  babyhood,  suffers  (unconscious 
perhaps  of  the  fact)  from  a  variety  of  symptoms  which  indicate  the 
"strain  "  to  Avhich  it  is  subjected  in  consequence  of  its  efforts  to  see  dis- 
tinctly. Its  eyes  are  liable  to  become  easily  suffused  when  it  plays  or 
looks  steadily  at  near  objects.  A  slight  cast  in  the  eye  is  sometimes 
developed.  It  occasionally  "  sees  double  "  after  it  learns  to  read.  It 
usually  prefers  and  excels  in  out-of-door  sports,  which  require  only 
slight  efforts  at  accommodation  of  vision.  It  finds  that  study  and  close 
application  to  books  bring  an  indescribable  sense  of  weariness  and  dis- 
comfort; hence,  study  becomes  irksome  and  play  brings  a  sense  of  pecu- 
liar relief.  Some  years  ago  Dr.  Loring,  of  this  city,  wrote  an  article  foi- 
Harper'' s  Moiithhi  which  treated  of  hypermetropia  and  m3'opia  in  a 
charmingly  lucid  and  popular  manner. 

*  This  is  probably  due  to  the  shallowness  of  the  orbits. 

f  Dr.  George  T.  Stevens  was  the  first,  so  far  as  I  know,  to  advance  the  general  propo- 
sition that  ocular  defect  was  an  important  factor  in  causing  functional  nervous  diseases, 
that  muscular  insufficiency  (chiefly  of  the  externi)  was  particularly  apt  to  cause  such  dis- 
turbances, and  that  they  could  be  relieved  by  tenotomy.  I  have  an  epileptic  child  under 
my  care  at  the  present  time  whose  attacks  liave  averaged  four  a  day  for  several  years.  The 
fits  will  cease  at  once  when  the  child  is  at  xea,  possibly  because  efforts  of  accommodation  are 
almost  entirely  dispensed  with  when  on  deck.  Hypermetropia,  astignuatism,  and  external 
insufficiency  exist  in  this  patient.  The  use  of  atropine  caused  a  complete  cessation  of  the 
fits  for  several  days.  Why  cannot  the  eye  act  as  a  disturbing  element  as  well  aspiiimosis, 
sexual  excesses,  ovarian  irritations,  etc.,  concerning  which  so  much  has  been  written? 

J  It  is  a  well  recognized  fact  that  people  who  are  victims  to  siek-headachea  early  in 
life  tend,  as  a  rule,  to  suffer  less  from  such  attacks  after  the  age  of  forty.  This  is  not 
generally  attributed  (as  in  my  opinion  it  should  be  in  many  cases)  to  the  enforced  use  of 
glasses  in  writing,  sewing,  reading,  and  other  forms  of  near  eye-work.  Most  of  this  class 
of  sufferers  are  hypermetropic  to  a  marked  degree  ;  hence  they  are  compelled  to  relieve 
their  "  accommodation  "  by  a  glass  earlier  than  most  adults. 

These  subjects,  therefore,  do  not  "  outgrow  their  malady  ;''  nor  does  the  eye  improve 
in  regard  to  its  refractive  error  as  age  advances.  They  simply  aid  the  eye  at  last  with  a 
glass,  which  it  has  too  long  needed  ;  not  voluntarily  in  most  instances,  but  from  eomj)ul- 
sion,  because  the  focusing  muscle  of  that  oigan  is  unable  after  a  while  to  continue  to  woik 
under  the  strain  which  the  refractive  error  has  eutaik'd  upon  it. 


THE   HYPERMETROPIC   EYE. 


127 


Now,  one  peculiur  liift  should  Ite  noticed  here — viz.,  tliat  Jii/per- 
metropiv  i<ubjeclx  often  have  remarkable  aculeaeaH  of  i^igJit.  They  Jire  veiy 
apt  (when  young  adults)  to  boast  of  their  power  of  vision.  They  can  often 
read  all  the  test-types  made  for  distance  (tAventy  feet  or  more)  without 
an  error.  If  the  defect  exists  in  a  child,  the  parents  will  frecpiently  tell 
vou  how  the  child  can  see  things  wntli  distinctness  which  possil)ly  they 
themselves  cannot  see  at  all;  how  they  have  tested  its  eyes  from  time  to 
time;  how  absurd  the  idea  seems  to  them  and  their  friends  that  the  vision 
of  the  child  is  defective;  and  how  unnecessary  the  use  of  glasses  seems 
to  them  (even  if  the  eye  is  abnormal)  so  long  as  the  child  can  get  along 
without  them.  In  some  cases  no  amount  of  explanation  or  jjleading  will 
persuade  the  parents  to  have  atropine  used  upon  the  child's  e^-es  in 
order  to  positively  decide  the  question  of  the  existence  of  "  latent " 
far-si  shtedness. 


Fig.  .39. — Section  of  the  Fkont  Part  of  the  Eye,  Showing  the  Mechanism  of  Ac- 
commodation. (Fick.)  The  left  side  of  the  figure  (F)  shows  the  lens  adapte.l  to  vision 
at  distances  of  over  twenty  feet;  the  right  side  of  the  figure  (A')  shows  the  lens  adapted  to 
the  vision  of  near  objects,  the  ciliary  muscle  being  contracted  and  the  suspensory  ligament  of 
the  lens  consequently  relaxed. 

Some  years  ago  I  pleaded  with  a  medical  man  to  allow  some  oculist  of 
reputation  to  examine  his  children's  eyes,  all  of  whom  bad  weekly  attacks 
of  sick-headache,  inherited  from  both  the  mother  and  father,  and  in  whom 
a  tubercular  tendency  was  strongl}-  marked.  I  was  refused,  and  the  state- 
ment was  made  that  never,  while  the  father  lived,  should  a  child  of  his 
wear  glasses  with  his  consent.  One  of  these  children  wears  to-day  a  con- 
vex glass  with  a  twelve-inch  focus  for  distance;  another  wears  the  same 
glass  with  five  degrees  of  prisms  added.  These  only  partially  correct  an 
insufficiency  of  the  muscles  wdiich  exists  in  addition  to  the  hyperme- 
tropia.  A  third  child  is  highly  hypermetropic  and  astigmatic.  In  every 
one  of  these  subjects  immense  relief  has  been  aflforded  hy  the  correction 
of  an  optical  defect  which  had  rendered  their  earlj-  life  one  of  suffering. 
This  is  not  an  uncommon  experience.  I  could  cite  many  more,  if  I 
deemed  it  necessary  to  prove  wdiat  is  already  accepted  by  ophthalmolo- 
gists as  proved — viz.,  that  h3'permetropia  and  e^-e-defect  of  other  forms 
may  prove  to  he  fruitful  sources  of  headache. 


128  LECTURES   ON   NERVOUS   DISEASES. 

There  is  a  prejiKlice  lunoiiLT  hiyiiu'ii  and  some  ■medical  men  that 
glasses  are  nn  injury  wlien  they  can  be  avoidrd;  because,  as  they  saj',  "a 
person  becomes  so  dependent  upon  tliem  when  he  once  puts  them  on." 
This  argument  shouhl  be  exactly  reversed,  and  construed  as  follows: 
Because  nature  becomen  dependent  upon  a  glass  which  gives  relief  and 
corrects  an  existing  strain  upon  the  ei/e,  no  time  should  be  lost  in  afford- 
ing this  relief. 

Should  a  hip-s])lint  be  avoided  (when  the  pain  in  the  joint  is  arrested 
b^'  it)  because  the  ])atient  feels  his  dependence  u])on  the  splint?  Should 
a  child  be  allowed  to  go  through  life  with  a  deformed  eye  simply  because 
the  defect  is  not  apparent  to  himself  or  his  friends  on  account  of  an  un- 
naturalh'-developed  ciliary  muscle  (see  Fig.  39),  which  for  a  time  renders 
the  eye  capable  of  getting  along  tolerably  well  in  spite  of  its  deformity? 

More  harm  is  being  done  to-dny  to  the  community  at  large  by  this 
fallacious  argument  than  it  is  possible  to  compute.  Thousands  of  suf- 
ferers from  sick-headache  and  neuralgia  are  to-day  struggling  along 
through  life  with  an  optical  defect  uncorrected,  and,  in  many  instances, 
after  costly  experimentation  with  drugs  and  doctors,  are  left  in  despair 
of  cure. 

I  speak  strongly  upon  this  point  because  I  believe  that  the  gastric 
symptoms  which  accompany  tjpical  attacks  of  sick-headache  are  not  to 
be  explained  (as  they  commonl}'  are)  on  the  ground  that  the  "liver  is 
inactive,''  or  that  "d^-spepsia  exists,"  or  that  "the  gastric  juice  is  weak," 
or  that  "the  patient  uses  tobacco  to  excess,"  or  that  "he  has  been  living 
too  high."  Every  one  who  has  suffered  for  j-ears  with  these  attacks  knows 
that  they  often  occur  without  explainable  cause;  that  they  are  cured  some- 
times by  eating,  drinking,  and  smoking,  and  made  worse  at  other  times 
by  similar  indulgences  or  excesses;  that  every  known  remedy'  is  apt, 
sooner  or  later,  to  prove  inoperative,  and  that  a  sure  specific  for  them  is 
unknown  among  che  drugs  of  our  Pluirmacopoeia.  These  sul>jects  also 
know  that  life  is  rendered  almost  unendurable  by  the  attacks  at  times. 
They  are  tractable  patients,  and  will  try  anything,  live  in  any  way 
specified,  and  bear  any  privation  w'ithout  a  murmur,  if  it  will  insure  a  cure. 

I  believe,  from  a  personal  experience  of  my  own  of  this  kind  (which 
it  is  unnecessary  to  relate  here),  and  from  some  experience  also  in  exam- 
ining the  eyes  of  this  class  of  sutferers,  that  the  S3'mptoms  of  sick-head- 
ache are  reflex  in  character  to  a  large  extent,  and  are  due  primarily-  in 
almost  every  case  to  some  ocular  defect.  We  can  easily  demonstrate 
that  disturbed  brain-action  from  "  e^-e-strain  "  may  produce  in  a  healthy 
child  and  in  some  adults  all  of  the  sj^mptoms  of  these  attacks  in  a  few 
minutes.  Why  is  it  irrational,  therefore,  to  affirm  that  a  brain  (disturbed 
b}'^  the  constant  efforts  made  to  use  e^'es  which  are  abnormal  in  respect 
to  the  refraction,  accommodation,  or  tlie  o([uilibrium  Avliich  should  exist 


THE   MYOPIC   EYE.  129 

between  its  various  muscles)  may  manifest  its  disturbed  state  by  nausea, 
lieadaclie,  vomiting,  dizziness,  constipation,  and  other  evidences  of  im- 
perfect performance  of  the  functions  of  the  viscera?  Does  not  our  cen- 
tral nervous  system  regulate  and  directly  control  those  functions  ?  Is  it 
not  as  probable  that  the  master  when  upset  disturbs  the  servants  under 
him,  as  to  advance  the  argument  that  the  servants  themselves  are  the  all- 
important  factors  in  causation  ? 

THE   MYOPIC   EYE. 

When  the  eye  is  too  long  from  before  backward,  the  patient  is  said 
to  be  "  myopic,"  or  near-sighted.  Distant  objects  are  more  or  less  indis- 
tinct to  such  an  eye  in  proportion  to  the  excessive  length  of  the  antero- 
posterior axis  of  the  eye  over  the  normal  standard.  No  amount  of  mus- 
cular etibrt  can  overcome  or  improve  this  defect  in  vision ;  hence  these 
individuals  are  not  subjected  to  the  muscular  strain  which  fai*-siglited 
persons  constantly  auvl  unconsciously  exert  in  order  to  see  at  a  distance. 
Again,  the  near-sighted  eye  can  read  or  perform  any  of  the  functions 
required  of  it  (when  brought  sufficiently  close  to  the  object)  without  any 
muscular  effort  of  an  unnatural  character.  In  contrast,  the  far-sighted 
eye  has  to  exert  a  still  greater  muscular  eff'ort  to  see  near  objects  dis- 
tinctly than  when  employed  upon  distant  objects;  hence  the  fatigue,  the 
blurring  of  letters  upon  a  printed  page,  the  watering  of  the  eyes,  the  pain 
in  the  eyes  and  head,  and  the  man}'  other  ills  previously  described. 

Near-sighted  subjects  are  generally  conscious  of  an  e3^e-defect,  be- 
cause they  cannot  see  across  a  room  with  distinctness  or  recognize 
familiar  faces  on  the  street.  They  are  apt  to  become  very  fond  of  occu- 
pations which  brings  the  eye  close  to  their  work,  because  they  have  no 
difficulty  in  seeing  the  object.  Neai'-sighted  children  are  liable  to  be  con- 
sidered precocious  beyond  their  years,  because  they  prefer  to  read  rather 
than  to  play  out-of  doors.  It  is  generally  safe  to  conclude  that  a  child  is 
near-sighted  when  it  avoids  out-of-door  amusements  in  order  to  gratify  a 
taste  for  reading  or  in-door  occupations. 

Near-sightedness  is  less  liable  to  induce  nervous  disturbances  than 
far-sightedness,  provided  it  is  not  accompanied  by  astigmatism  or  mus- 
cular insufficiency.  Yet  it  should  be  remembered  that  myopic  subjects 
are  more  frequently  sent  to  the  oculist  for  relief  than  hypermetropic 
subjects  are,  because  the  defect  in  vision  is  very  apparent  to  all  in  the 
former  class,  and  is  more  often  unsuspected  than  recognized  in  the  latter. 

THE   ASTIGMATIC   EYE. 

You  may  find,  in  the  third  place,  when  3'ou  have  examined  the  eyes 
of  patients  or  friends  who  suffer  from  headache,  persistent  neuralgic 
attacks,  etc..  that  a  condition  of  the  eye  known  as  ^^ astigviatism,^'  may 

9 


130  LECTURES   ON   NERVOUS   DISEASES. 

be  detected,  co-existing  with  far-  or  near-sightedness,  or  independent  of 
these  refractive  errors.  In  such  subjects  the  cornea  or  the  lens  of  the 
eye  (see  Fig,  39)  has  a  greater  curvature  in  some  meridians  than  in 
others;  hence  the  images  of  all  objects  seen  are  more  or  less  distorted 
when  they  fall  ui)on  the  retina.  To  this  class  of  sufferers  some  letters  in 
the  tests  employed  will  be  distinct,  while  others  will  not.  If  a  number 
of  dots  are  made  upon  a  blackboard  or  a  sheet  of  paper,  some  will  appear 
as  ovals,  with  a  hazy  border,  or  as  lines,  while  others  will  more  closely 
resemble  the  normal  appearance  of  the  dots.  Finally,  if  a  card,  with 
lines  running  from  its  centre  to  its  periphery  (the  "clock-face  test"),  is 
used,  some  of  the  lines  will  appear  blacker  than  the  rest  and  more  clearly 
defined.  Now,  there  can  be  no  comfort  to  such  subjects  in  their  visual 
efforts.  They  learn  l)v  practice  and  experience  to  properly  interpret, 
after  a  while,  the  imperfect  images  of  objects  seen,  and  they  are  aided  in 
so  doing  by  the  fact  that  the  outlines  of  letters,  etc.,  become  clearer  in 
some  positions,  as  regards  the  eyea,  than  in  others;  but,  in  spite  of  all 
that  may  be  said  to  the  contrary,  the  strain  of  using  imperfect  eyes  tells 
upon  most  astigmatic  persons  sooner  or  later,  and  tends  to  excite  reflex 
nervous  phenomena  of  various  kinds.  To  properly  correct  astigmatism 
bj'  glasses  is  often  an  extremely  difficult  matter.  It  requires  experience, 
a  thorough  knowledge  of  optics,  and  a  familiarit}^  with  the  practical  use 
of  the  ophthalmoscope.  There  are  comparatively'  few  physicians  (outside 
of  the  specialists  in  ophthalmology')  who  are  capable  of  managing  a  bad 
case  of  this  kind  with  perfect  success.  You  can,  however,  easilj^  detect 
its  existence  in  most  cases.  When  you  discover  it.  I  would  advise  you 
to  intrust  its  correction  to  skillful  hands. 

Certain  abbreviations  are  employed  by  oculists  to  designate  various 
forms  of  astigmatism  which  may  be  detected.  These  are  of  use  in  re- 
cording the  results  of  an  examination : — 

Ah.  stands  for  simple  hypermetropic  astigmatism. 

Am  stands  for  simple  myopic  astigmatism. 

H  -\-  Ah  stands  for  compound  hypermetropic  astigmatism. 

M  -(-  A)a  stands  for  compound  myopic  astigmatism. 

31  -j-  Ah,  or  H  -\-  Am,  stands  for  mixed  astigmatism. 

THE   ASTHENOPIC   EYE. 

Finally,  it  is  very  important  that  you  determine  (in  each  patient 
whose  eyes  are  examined  by  you)  the  condition  of  the  muscles  of  the  eye. 
The  term  "  asthenopia  "  is  commonly  applied  to  that  condition  of  the 
visual  apparatus  which  entails  suffering  in  consequence  of  a  defective 
"equilibrium"  in  the  muscular  power  exerted  upon  that  organ  when  a 
fixed  position  of  the  e^-e  is  maintained  for- any  length  of  time.  When  a 
state  of  i^erfect  equilibrium  is  impaired  from  a  weakness  in  some  muscle 


THE   ASTHENOPIC   EYE.  131 

of  the  e3'e,the  effects  become  manifested  sooner  or  later  by  pain  and  great 
discomfort  after  the  eyes  are  nsed  for  any  length  of  time.  I  have  seen 
patients  who  conld  not  attend  a  place  of  amusement,  or  read  or  sew,  for 
even  a  short  time,  without  great  distress  from  this  cause.  These  patients 
may  or  may  not  have  a  refractive  error.  In  some  instances,  no  glasses 
but  prismatic  ones  will  benefit  them. 

A  high-couraged  horse  feels  the  will,  as  well  as  the  support,  of  his 
driver  through  the  reins  by  means  of  the  bit.  Although  his  course  and 
rate  of  speed  are  changed  from  time  to  time  at  the  will  of  the  driver,  the 
reins  are  never  slackened.  The  horse  becomes  acquainted  with  the  de- 
sires of  his  master  by  a  sense  of  increased  or  diminished  tension  upon  the 
reins.  He  is  guided  to  either  side  by  a  difference  in  the  tension  of  the 
two,  although  the  driver  does  not  entirely  relax  his  hold  upon  the  op- 
posing rein  while  he  uses  the  guiding  one,  and  the  difference  in  tension 
ma^'  be  very  slight. 

So  it  is  with  the  normal  e^^e.  It  is  both  controlled  and  sup])orted 
while  performing  its  movements  within  the  orbit  by  the  e3'e  muscles  (which 
are  its  reins).  The  brain  is  the  driver.  At  its  command  the  ej'e  revolves 
or  remains  stationary  at  any  desired  point.  The  tension  of  muscles, 
opposed  to  any  movement  of  the  eye  required,  is  so  modified  by  the  brain 
as  to  insure  the  requisite  support  to  tlie  eveball,  and  to  steady  it  as  it 
moves.  Thus  a  perfect  equipoise  is  constanth'  established  between  op- 
posing forces,  adjusted  with  the  nicest  care  to  meet  the  full  requirements 
of  the  organ  under  all  possible  circumstances.  Tlie  noi-mal  e3'e  does  not 
tremble  or  wabble  w^hen  it  moves  or  the  attempt  is  made  to  hold  it  in  any 
fixed  attitude.  It  is  a  piece  of  machinery,  perfect  in  all  its  parts,  reliable 
in  its  movements,  perfectly  controlled  b}'  its  master. 

The  eye  with  "muscular  insufficiency"  is  like  a  horse  with  an  inex- 
perienced and  incompetent  driver;  the  proper  tension  upon  the  reins  is 
not  maintained  at  all  times,  as  it  should  be;  there  is  no  equilibrium  be- 
tween antagonistic  muscles;  fixed  attitudes  are  maintained  with  difficulty 
for  au}^  length  of  time;  the  brain  becomes  more  or  less  disturbed  by  its 
inability  to  properly  control  the  e3e  movements,  and  exhausted  by  the 
continual  strain  imposed  upon  it  b}'  the  efforts  required  to  do  so  even 
imperfectl}'. 

Asthenopic  subjects  are  very  frequently  encountered  in  the  practice 
of  a  neurologist.  The  oculist,  perhaps,  sees  them  still  oftener,  because 
they  are  generally  conscious  that  something  is  wrong  with  their  ayes. 
Still,  there  are  exceptions  to  this  rule.  I  have  examined  patients  who 
showed,  in  response  to  appropriate  tests,  ver^^  liigh  degrees  of  muscular 
"insufficiency,"  that  came  to  me  for  tlie  relief  of  symptoms  which  had 
never  been  referred  by  themselves  or  their  pliysician  to  an^^  possible  eye 
defect.    I  recall  the  case  of  an  epileptic  who  was  placed  under  m^-  charge. 


132  LECTURES   ON   NERVOUS   DISEASES. 

His  family  assured  me  ho  had  "wonderful  eyes;"  and  they  wore  sur- 
prised when  I  examined  tliem  with  care.  The  results  of  this  examination 
showed,  however,  that  twenty-live  degrees  of  external  insuflicienc}^  ex- 
isted (as  measured  l\y  the  vertical  diplopia  test),  and  that  he  was  hyper- 
metropic and  astigmatic  to  a  marked  degree. 

InsulKciency  of  ocular  muscles  seems  to  me  to  be  a  congenifal  defect 
in  most  cases — possibly  in  all.  It  is  encountered  in  very  ^oung  subjects. 
It  is  not  a  paralysis  or  a  true  paresis.  It  is  not  uncommon  to  note  wide 
variations  in  the  same  case,  if  examinations  are  made  from  time  to 
time.  Possibly  this  fact  helps  to  explain  why  competent  observers  do 
not  always  estimate  the  degree  of  insufficiency  in  a  given  case  alike, 
even  when  similar  tests  are  employed  and  equal  care  is  given  to  the  case. 
We  have  no  way  as  yet  of  determining  ^- latent^'  insufficiency^'^  as  we 

^Because  this  term  was  used  by  me,  in  a  prior  publication,  I  have  received  several 
communications  from  oculists  of  prominence  denying;  the  existence  of  "latent"  or  hidden 
insuOuiency,  and  taking  me  to  task  for  the  use  of  such  an  expression.  I  would  state, 
therefore,  that  there  are,  to  my  mind,  most  positive  evidences  that  the  condition  thus  de- 
scribed does  exist  in  some  cases ;  in  fact,  I  would  go  so  far  as  to  assert  that  it  is  the  rule, 
rather  than  the  exception,  to  find  a  certain  amount  of  masked  insufficiency,  in  connection 
with  "functional"  nervous  maladies,  that  cannot  be  elicited  by  any  means  yet  known  to 
the  science  of  optics. 

!My  experience  in  relieving  ocular  "insufficiencies"  by  tenotomy  of  the  recti  muscles 
has  shown  me  that  the  amount  of  tissue  divided  is  almost  always  greatly  in  excess  of  the 
apparent  defect  to  be  overcome.  Again,  after  the  eyes  have  been  perfectly  balanced  by  a 
tenotomy  (as  shown  by  careful  tests  made  after  the  operation),  it  is  very  frequently  found 
that  more  "insufficiency"  develops  within  a  short  time  than  was  detected  before  surgical 
interference  was  resorted  to  as  a  step  for  its  correction.  In  the  third  place,  I  have  found 
that  repeated  tenotomies  (performed  as  often  as  indicated  by  the  tests  described)  eventu- 
ally bring  the  patient  to  a  point  tohere  the  eyes  remain  permanejitly  corrected — a  fact  that 
proves  quite  conclusively  the  error  of  supposing  that  the  tenotomy  was  in  any  way  re- 
sponsible for  the  lack  of  equilibrium  which  developed  later.  In  the  fourth  place  I  have 
found  it  to  be  advisable  in  some  cases  to  cut  the  muscles  to  excess,  so  as  to  over-correct  an 
error  in  equilibrium — knowing  that  by  so  doing  I  anticipate  a  certain  amount  of  "latent" 
insufficiency,  which  will  assist  in  making  the  results  more  satisfactory  to  the  patient 
within  twenty-four  or  forty-eight  hours. 

If  it  were  necessary,  in  my  opinion,  to  argue  this  question  at  greater  length,  I  might 
add  (1)  that  a  persistent  wearing  of  prisms  for  the  correction  of  insufficiency  almost  in- 
vai'iably  results  in  the  development  of  a  latent  weakness  of  the  muscles  not  discovered  at 
first;  (2)  that  persistent  daily  exercise  of  the  eyes  by  prisms  usually  accomplishes  the 
same  result;  and  (3),  that  my  views  arc  in  accord  with  all  who  have  had  much  experience 
in  the  use  of  prisms — irrespective  of  partial  tenotomies,  which  demonstrate  the  facts  even 
more  satisfactorily. 

I  take  the  liberty  of  quoting  from  the  late  work  of  Prof.  H.  D.  Noyes  (pp.  87  and  89) 
the  following  passages  : — 

"Give  due  opportunity  for  disclosiire,  and  what  at  first  seemed  to  be  a  moderate  de- 
gree (referring  to  insufficiency)  may  at  length  declare  itself  in  much  larger  proportions." 

"While  great  advantage  is  gained  by  Graefe's  test,  it  is  not  true  that  latent  insuf- 
ficiency is  always  thus  brought  to  view." 

Aeain,  I  may  quote  from  a  late  article  by  Dr.  G.  T.  Stevens  as  follows  :  "  Muscular 
anomalies  of  the  orbit  may  be  totally  or  partially  latent." 


THE   TESTS   OF   VISION    AND    OCULAR   MOVEMENTS.  133 

do  latent  li3-permetroi)ia  b}-  atropine.  Should  a  patient  show  us  an 
insufficiency  counteracted  by  a  prism  of  a  certain  angle  to-day,  it  only 
proves  that  he  has  at  least  that  amount,  not  that  he  has  no  more.  This 
statement  can,  I  think,  be  demonstrated.  It  is  an  important  fact  to 
remember  when  the  results  of  examinations  of  such  patients  made  by 
yourself  are  at  variance  with  the  observations  made  by  another. 

Without  further  preparatory^  remarks,  I  pass  to  the  consideration  of 
the  steps  commonly  taken  to  determine  if  the  eye  (regarded  purely  as  a 
piece  of  mechanism)  is  perfect  or  imperfect.  The  study  of  the  e\-e,  when 
Q,\\y  of  its  component  parts  become  the  seat  of  disease,  has  no  bearing 
upon  the  subject  under  discussion.  This  field  is  properly  relegated  to 
oculists. 

THE   TESTS    OF   VISION   AND   OCULAR   MOVEMENTS. 

The  steps  Avhich  should  be  emplo^'ed  in  examining  the  e\'e  for  errors 
in  refraction  and  accommodation,  as  well  as  those  employed  to  detect 
defect  in  the  power  of  ocular  muscles,  have  not  thus  far  been  discussed. 
I  expect  to  offer  nothing  new,  but  I  hope  to  make  the  details  of  such  an 
examination  simple  and  within  the  comprehension  of  all. 

The  importance  of  this  department  of  diagnosis  can  hardly  be  over- 
estimated in  nervous  maladies.  It  has  been  my  custom  for  three  years  past 
to  examine  the  vision  of  nearly  every  patient  sent  to  me,  as  my  experience 
has  shown  me  many  times  that  remarkable  cures  may  be  made  by  the  light 
thus  shed  upon  the  causation  of  obscure  nervous  s^^mptoms. 

Unfortunately  for  the  sick,  in  man\^  instances,  physicians  in  general 
seem  to  think  that  the  examination  of  the  eye  is  too  difficult  a  field  for 
them  to  intrude  upon  without  some  special  preparation  for  it.  While 
this  is  undoubtedly  true,  in  case  the  ophthalmoscope  is  to  be  employed, 
it  is  b}'  no  means  a  difficult  matter  for  a  person  acquainted  with  physics 
to  acquire  a  practical  and  satisfactory  knowledge  of  the  few  tests  here 
described  in  a  comparatiA-ely  short  time,  and  with  but  a  limited  number 
of  patients,  provided  that  he  works  faithfully  and  intelligently.  The 
healthy  (?)  as  well  as  the  sick  can  often  be  used  to  familiarize  the  be- 
ginner with  the  practical  adjustment  of  prismatic,  spherical,  and  cylin- 
drical glasses,  and  also  with  the  tests  enq^loyed  to  detect  "asthenopia" 
or  anomalies  of  the  eye-muscles. 

Pelective  vision  does  not  always  produce  ill  health;  hence  among 
your  friends  or  in  ^our  immediate  famil}'  you  may  find  a  field  for  inves- 
tigation and  practice. 

iS'oAv,  in  the  first  place,  it  is  not  necesssar}"  to  have  a  complete 
Naehet  case  of  lenses.  Such  a  case  is  very  expensive.  By  selecting  a 
limited  assortment  of  lenses  and  prisms,  different  combinations  can  be 
made  to  meet  the  needs  of  almost  every  e^'e-defect  encountered  in  medical 
practice. 


134  LECTUEES   ON  NERVOUS   DISEASES. 

There  is  furnished,  Avitli  the  various  small  cases  designed  by 
prominent  oculists,  a  sheet  of  Snellen's  test-types  for  distance,  and  also 
one  contf ining  several  paragrajjlis  printed  in  an  assortment  of  t3pes  of 
various  sizes  to  be  used  as  a  test  for  reading  power.  Each  paragraph  is 
numbered  so  that  a  record  can  be  kept  of  the  one  read  b}'  the  patient  as 
a  test.  These  test-type  slips  can  be  purchased  separately,  however,  of 
any  optician.  It  is  best  to  have  each  mounted  on  card-hoard,  and  it  is 
well  to  have  the  one  used  in  testing  for  distance  a  double  one  with  dif- 
ferent letters  on  the  opposed  sides.  If  you  suspect  that  the  patient  is 
using  his  memory  during  the  tests  employed  rather  than  his  sight,  the 
board  can  then  be  exposed  upon  diflerent  sides  at  various  periods  of  the 
examination. 

You  will  find  that  the  letters  are  mathematically  made  for  testing 
distant  vision.  Above  each  line  a  numeral  or  Roman  character  is  placed 
to  designate  the  number  of  feet  at  ivhich  the  normal  eye  should  read  the 
line  with  ease.  Thus,  the  large  letter  on  the  top  line  will  be  designated 
usually  by  200,  or  C  C,  while  small  letters  of  the  lower  line  will  be  marked 
10,  or  X.  This  shows  that  the  top  letter  should  be  read  easily  at  two 
hundred  feet  by  the  normal  eje,  and  the  lower  line  at  ten  feet.  After 
you  have  provided  yourself  with  a  good  trial-case,  a  set  of  prisms,  and 
the  necessary  test  t^-pe,  let  us  see  how  you  should  proceed  with  an  exami- 
nation of  a  patient's  vision.  AVe  may  illustrate  the  steps  by  using  one 
of  the  class  as  a  patient. 

I  first  hang  upon  the  wall,  as  you  see,  the  test-type  card;  and 
I  place  the  patient  with  his  eye  on  the  same  level  and  at  a  distance  from 
it  of  exactly  twenty  feet.  I  then  take  the  triple-grooved  spectacle  frame 
from  the  trial  case  and  insert  a  plate  of  metal  in  the  left  rim  of  the  frame, 
so  that  when  it  is  used  by  the  patient  the  left  eye  will  be  covered.  I 
then  place  this  frame  upon  the  patient,  and  ask  him  to  read  aloud  the 
letters  on  the  testing  card  from  the  top  downward,  line  b}'  line.  This 
act  tests  his  vision  in  the  right  eye.  I  note  (while  he  reads)  the  following- 
facts:  (1)  If  he  calls  all  the  letters  properly;  (2)  if  he  reads  without  ap- 
parent effort;  (3)  at  ivltat  line  he  fails  to  read.     I  then  make  a  record 

20  (feet) 
as  follows:  O.  D.  (oculus  dexter,  or  right  eye)  V  =  —  .   The  dash 

—  (type) 

in  the  fraction  is  filled  with  the  number  which  indicates  the  last  line  which 
the  patient  reads.     Wiien   the  vision  is  normal,  the  fraction  will  be  as 

20       20 
follows  :  \.  =  —  or  — .     If  the  patient  fails  at  the  line  next  above  the 
20       XX 

20        20 

normal  point  the  fraction  would  be  expressed  T)y  —  or .     Remember 

oO       XXX 
that  the  numerator  represents  the  distance  (in  feet)  between  the  patient 


THE   TESTS    OF   VISION   AND   OCULAK   MOVEMENTS.  135 

and  the  test-t^-pe,  find  that  the  denominator  represents  the  numeral  on 
the  test  card  placed  above  the  last  line  of  type  read  by  the  patient 
(which  indicates  the  normal  distance  in  feet  at  which  it  should  be  legible 
to  the  normal  eye.  Now,  if  the  vision  of  the  right  eye  is  found  to  be 
defective,  try  and  improve  it,  and,  if  possible,  to  render  it  normal,  or 
as  nearly  so  as  possible,  by  testing  the  effects  of  concave  or  convex 
glasses  upon  it  as  the  case  seems  to  indicate,  beginning  with  the  weakest 
lenses  and  gradually  increasing  their  strength  until  the  vision  reaches  its 
highest  acuteness.  This  takes  some  little  practice  and  experience.  If 
convex  glasses  are  found  to  be  indicated,  note  the  strongest  which  gives 
the  best  vision  to  the  patient;  if  concave,  record  the  weakest  glass  that 
overcomes  the  defect. 

In  some  cases  you  may  find  yourself  unable  to  obtain  normal  vision 
in  either  eye  by  means  of  cylindrical  or  spherical  glasses.  I  presuppose 
a  certain  degree  of  acquired  facilit}'  on  your  part  with  glasses  of  the 
forms  specified,  and  a  carefully  made  effort  to  overcome  the  existing 
defect. 

In  such  a  case  it  is  well  to  consult  some  expert  oculist  (if  near  at 
hand),  and  thus  to  ascei-tain  the  results  of  an  ojDhthalmoscopic  examinatio7i. 
The  patient  may  have  some  mechanical  impediment  to  vision,  such  as  an 
opaque  lens  within  the  eye  (cataract),  or  an  opacity  of  the  cornea;  or  he 
may  have  a  high  degree  of  astigmatism,  which  can  often  be  estimated 
with  some  accuracy  by  the  ophthalmoscope.  Again,  he  may  be  found  to 
be  suffering  from  morbid  changes  within  the  optic  nerve  or  the  retina. 

When  it  is  found  that  a  patient  is  so  blind  in  an  eye  as  to  be  unable 
to  recognize  any  of  the  letters  on  the  testing-card  at  any  distance,  you 
should  note  (before  sending  him  to  an  oculist)  if  he  can  recognize  with 
accurac}^  the  number  of  fingers  which  you  hold  before  the  eye,  and  record 
the  results  of  such  investigation.  You  should  make  this  test  Avith  the 
fingers  in  all  possible  positions  in  reference  to  the  diseased  eye  (directly 
in  front,  above,  below,  and  to  either  side  of  it). 

We  might  record  the  results  of  an  examination  of  a  suppositious  case 
up  to  this  point  as  follows : — 

20  20 

O.  D.  Y.  =  (manifest)  made  • —  by  -f  30  glass. 

XXX  XX 

The  word  "  manifest "  in  this  record  means  that  the  far-sightedness  or 
"hypermetropia,"  which  apparenth/  eK\sts,\s  overcome  by  a  convex  or 
(-[-)  glass  which  focuses  at  thirty  inches.  After  the  use  of  atropine,  any 
increase  over  this  amount  whicli  may  be  developed  is  recorded  as  "  latenf'' 
far-sightedness.  I  use  here  the  old  st^de  of  numbering  glasses  for  the  sake 
of  perspicuity,  although  I  personally  prefer  the  metric  system  (dioptre), 
as  it  allows  of  more  rapid  combinations  when  the  trial-case  contains  only 
a  limited  supply  of  lenses. 


136  LECTURES   ON   NERVOUS   DISEASES. 

Yon  will  understnnd,  when  I  exhibit  the  method  of  recording  such 
observations  more  fully  to  you,  why  it  is  that  the  right  and  left  ej-es  have 
to  be  separately  examined  and  corrected  (as  already  described)  before 
the  binocular  vision  is  tested  with  and  wit4iout  the  needed  correction.  I 
usually  make  upon  the  page  of  my  own  ease-book  a  note  relating  to  each 
eye  of  the  patient,  prior  to  the  use  of  atropine  somewhat  as  follows: — 

20  20 

0.  D.  (right  eye)  T.  :== (manifest)  made  —  by  +  30. 

XXX  XX 

20  20 

O.  S.  (left  eye)  Y.  =  —  made  —  by  —  30 
xl  XX 

20  20 

Binocular  Y.  = made  —  b}^  this  comhination. 

XXX  XX 

Such  a  record  of  a  suppositious  case  would  show  that  the  patient  was 
far-sighted  or  "  hypermetropic  "  in  the  right  eye,  and  near-sighted  or  "  my- 
opic^^  in  the  left  eye.  It  would  lead  me  to  believe  also  that  the  right  eye 
(when  under  the  influence  of  atropine)  might  show  a  still  greater  defect, 
which  is  now  rendered  "latent,"  or  hidden,  b}^  an  excessive  development 
of  the  muscle  of  accommodation. 

In  all  far-sighted  eyes  Nature  tries  from  the  date  of  birth  to  com- 
pensate for  the  congenital  defect  (an  eve  which  is  too  flat)  b}-  a  h^i^er- 
trophy  or  enlargement  of  the  ciliary  muscle  (see  Fig.  39);  hence,  when 
this  muscle  is  temporaril}^  paral^'zed  b}'  atropine,  the  true  refractive  con- 
dition of  the  eye  is  no  longer  masked.  Far-sighted  patients,  therefore, 
lose  their  clearness  of  vision  more  or  less  at  once  when  atropine  is  used. 
The  normal  or  the  "myopic"  eye,  on  the  contrary,  is  but  little  atfected 
(as  regards  the  outline  of  objects  seen  at  twenty  or  more  feet  from  the 
eye)  b^-  the  use  of  atropine,  although  excessive  light  may  anno}'  the  eye 
in  any  case. 

Let  us  now  suppose  that  during  the  examination  of  a  patient  we  first 

have  examined  each  eye  separately,  carefulh'  corrected  all  existing  error 

20 
found,  and  succeeded  in  getting  — ,  or  normal  vision,  for  each  eye  sepa- 

XX 

rately ;  that  we  have  then  tried  both  eyes  together  with  the  glasses  best 
adapted  for  each,  and  found  the  patient  able  to  read  the  normal  type  for 
distance  without  fatigue  or  conscious  effort ;  and,  finally,  that  we  have  made 
a  careful  record  of  each  point  noted  during  our  observations.  Are  we  now 
prepared  to  order  glasses  for  the  patient?  Have  we  noted  all  that  is  im- 
portant to  note?  To  both  of  these  inquiries  I  would  sa}' to  the  beginner, 
emphatically,  "  No."  Several  steps  still  remain  to  be  taken,  even  before 
the  use  of  atropine  (which  it  is  generally  best  to  employ  before  a  final 
decision  is  arrived  at). 


THE   TESTS   OF   VISION   AND    OCULAK   MOVEMENTS.  137 

This  brings  us  to  the  tests  for  the  detection  of  muscular  anomalies 
in  the  orbit. 

Until  within  a  comparatively  few  years  the  necessity  of  carefull3'^ 
measuring  the  power  of  adduction  and  of  abduction  of  the  eyes,  and 
of  determining  the  presence  or  absence  of  muscular  insufficiency  in 
"nervous"  subjects,  seems  to  have  been  practically  disregarded  even  by 
oculists.  Even  to-day  this  defect  (which  probably  is,  as  a  rule,  con- 
genital) seems  to  be  omitted  from  prominent  mention  among  the 
enumerated  list  of  ^etiological  factors  of  nervous  symptoms  by  almost 
all  authors  of  note.  In  some  cases  I  have  known  it  to  be  overlooked 
even  by  opthalmologists  of  world-wide  reputation,  simply  on  account  of  a 
careless  and  hasty  examination  for  the  defect.  It  is  an  extremely 
common  defect  of  the  eye ;  and  may  prove  a  very  serious  one  to  the 
patient.  It  is  an  important  factor  in  many  subjects  afflicted  with  head- 
ache ;  it  often  exists  to  a  high  degree  in  epileptics ;  it  is  frequently  found 
among  children  wdio  suffer  from  chorea;  it  ma}^  unfit  a  patient  for 
sewing,  reading,  attending  places  of  amusement,  or  using  the  eyes  in 
any  way  for  any  length  of  time.  I  have  known  it  to  cause  vomiting  and 
so-called  periodical  ''bilious  attacks"  by  exciting  a  reflex  irritability  of 
the  central  nervous  system.  One  patient  of  mine  (a  close  student)  was 
completely  cured  of  chronic  dyspepsia  by  the  use  of  prisms  "which  cor- 
rected an  insufficiency  of  G°  of  the  external  recti  muscles.  He  sub- 
sequently had  tenotomy  performed  and  now  uses  his  eyes  without 
fatigue.     All  bodily  ailments  have  disappeared  without  the  use  of  drugs. 

In  order  to  properly  determine  the  condition  of  the  ocular  muscles, 
several  tests  have  to  be  made.  I  do  not  personall}^  regard  any  of  these 
alone  as  sufficient  for  diagnostic  purposes.  The  tests  which  I  advise  3^ou 
to  invariably  employ  are  as  follows : — 

1.  Direct  the  patient  (as  you  see  me  do  with  a  member  of  the  class) 
to  look  fixedly  with  both  eyes  at  some  small  object  (say  the  end  of  a 
pencil),  and  to  follow  it  with  the  eyes  as  I  move  it  before  the  face  of  the 
patient  at  a  distance  of  about  ten  inches.  I  watch  both  eyes  carefully  at 
the  same  time  and  note  if  a  tremulous  movement  in  either  eye  is  present 
in  any  position  of  the  eye  as  it  moves  about,  and  if  the  two  eyes  act  in 
perfect  unison  with  each  other. 

2.  While  the  patient  is  instructed  to  fixedly  gaze  at  the  same  object, 
I  next  shield  one  eye  with  a  card  or  sheet  of  ]iaper  so  as  to  exclude 
the  object  from  view.  Now  I  shift  the  card  rapidly  from  one  eye  to  the 
other,  and  I  observe  at  the  same  time  any  deflection  or  trembling  of  the 
covered  eye,  which  may  shovv  itself  as  I  shift  the  card.  If  deflection  or 
trembling  occurs,  it  indicates  a  weak  muscle. 

3.  Deviations  of  the  visual  axis  of  an  eye  in  a  vertical  direction  are 
not  always  revealed  by  the  two  tests  previously  mentioned,  nor  are  they 


138  LECTURES   ON   NERVOUS   DISEASES. 

always  apparent  to  a  careful  obserA'er  of  faces.  They  are  of  the 
greatest  clinical  importance,  however,  and  should  be  looked  for  early 
in  the  examination.  A  pair  of  prisms  of  five  or  more  degrees  each  are 
placed  in  a  spectacle  frame  with  their  bases  inward*  in  order  to  overcome 
the  power  of  fusion  of  images  b}'  the  externi,  and  the  patient  is  directed 
to  look  through  them  at  a  candle  flame  placed  twenty  feet  from  the  pa- 
tient's eyes  and  on  the  same  level.  The  head  is  placed  in  natural  position 
for  distant  vision  and  steadied  by  a  photographer's  head-rest.  If  either  of 
the  two  candle  flames  (seen  by  the  patient  in  consequence  of  the  prisms) 
be  higher  than  the  other,  a  prism  is  selected,  which,  with  its  base  upward 
or  downward,  when  placed  before  one  eye  overcomes  the  defect.  The 
angle  of  this  prism  (in  degrees)  is  then  noted  and  recorded  in  the  case- 
book. 

4.  I  next  place  upon  the  patient  a  spectacle-frame  previously  ar- 
ranged with  a  disc  of  ordinary  glass,  tinted  red,  to  cover  one  eye,  and 
a  prism  of  5°,  with  its  base  directed  accurately  upward  or  downward, 
before  the  other  eye.  I  then  direct  the  patient's  vision  upon  a  candle- 
flame  at  a  distance  of  twenty  feet.  The  prism  causes  two  candles  to 
appear  (one  being  colored  red  by  the  glass  of  that  hue),  both  of  which 
to  the  normal  eye  should  be  seen  as  if  in  a  vertical  line.  If  the  red 
image  is  seen  to  the  same  side  of  an  imaginary  vertical  line  dropped 
through  the  white  image  as  the  eye  covered  with  the  red  glass,  the 
external  recti  are  insufificient ;  if  the  red  image  is  seen  on  the  opposed 
side  of  the  vertical  line,  the  internal  recti  muscles  are  weak.f 

5.  Any  deviation  of  the  candle  which  exists  can  be  remedied  easily 
by  placing  a  prism  with  its  base  outioard  before  one  eye  for  external  in- 
sufficiency, and  with  its  base  imvard  for  internal  insufficienc}'.  The 
strongest  correcting  prism  that  can  be  worn  without  an  over-correction 
marks  the  degree  of  the  "manifest"  insufficienc}'  only;|  hence  we  will 

*  Dr.  Stevens  had  devised  an  rectangular  and  elongated  form  of  glass  for  this  pur- 
pose.    Its  great  advantages  must  be  apparent  to  all  who  have  worked  in  this  field. 

1 1  have  lately  employed  in  my  consultation  room  a  device  which  seems  to  me  to  be 
of  great  assistance  to  patients  while  their  eye-muscles  are  being  tested.  It  consists  of  two 
pieces  of  white  tape  which  are  stretched  upon  a  dark  background  at  right  angles  to  each 
other  ;  so  that  one  lies  exactly  vertical  and  the  other  horizontal.  The  flame  from  a  small 
gas  burner  at  the  tip  of  a  porcelain  candle  lies  directly  opposite  to  their  point  of  intersec- 
tion and  between  them  and  the  eye  of  the  patient,  all  of  which  should  be  on  the  same 
level. 

During  the  tests  described,  the  patient  can  tell  at  once  if  either  line  appears  double 
as  well  as  the  image  of  the  candle  flame. 

I  My  experience  with  tenotomy,  as  a  means  of  producing  an  equilibrium  between 
opposing  forces  in  the  orbit,  has  convinced  me  that  the  amount  of  insufficiency  detected  by 
prisms  is  but  a  small  proportio7i  of  what  actitalhj  exists  in  some  cases.  A  persistent  use  of 
prismatic  glasses  will  often  develop  a  degree  of  insufficiency  which  the  patient  did  not  at 
first  apparently  possess.  In  my  experience  this  is  the  rule  rather  than  the  exception.  It  is 
comparatively  rare  for  me  to  encounter  a  case  where  a  full  correction  of  an  existing  insuffi- 


THE   TESTS    OF   VISION   AND   OCULAR   MOVEMENTS.  139 

note  variations  from  time  to  time.  I  usually  note  both  the  weakest  and 
the  strongest  prism  which  corrects  the  candle-deflection. 

6.  I  next  test  and  measure  the  jjower  of  adduction  and  abduction 
(convergence  and  divergence)  of  the  eyes  by  means  of  prisms.  To  do 
this  I  set  a  lighted  candle  twenty  feet  from  the  patient  on  a  level  with  his 
vision  when  seated.  I  then  hold  before  one  eye  a  prism,  tuiih  its  base  di- 
rected outward,  of  sufficient  angle  to  cause  two  images  of  the  candle  to 
appear  when  both  eyes  look  at  the  object.  I  then  instruct  the  j^atient  to 
make  an  endeavor  to  draiv  the  images  together  and  to  fuse  the  two  into  one 
image.  This  is  the  test  for  adduction  or  convergence.  The  normal  eye 
should  overcome  a  prism  of  at  least  23°  to  25°.  It  may  overcome  60° 
in  some  instances. 

In  the  same  way  a  prism  with  its  base  directed  inward  is  used  to 
test  the  2}0iver  of  abduction  or  divergence.  The  external  recti  muscles 
should  not  fail  to  overcome  a  prism  of  at  least  8°.  By  combining 
prisms  of  varying  angles,  one  of  the  requisite  angle  can  be  easily  ob- 
tained with  but  a  few  prisms  in  your  trial-case. 

The  power  of  abduction  and  adduction  should  alwaj^s  be  recorded 
v/hen  accurately  determined.  One  fact  should  be  stated,  however,  in 
this  connection — viz.,  that  several  sittings  are  usually  required  before 
the  patient  learns  to  use  his  ej^e-muscles  to  the  best  advantage;  hence 
the  records  of  daily  tests  should  be  kept  for  purposes  of  comparison 
for  a  short  time  (when  practicable  to  do  so). 

Y.  The  power  of  convergence  and  divergence  of  the  eyes  can  be 
estimated  for  near  objects  by  means  of  a  stereoscope  modified  by  Pro- 
fessor Henry  D.  Noyes,  into  which  prisms  may  be  dropped  at  will.  I 
have  used  it  of  late  with  some  satisfaction.  I  find  that  the  accommo- 
dation often  modifies  the  power  of  ocular  muscles  (as  determined  by 
the  previous  test  at  twenty  feet  distance).  Prisms  var^^,  moreover, 
according  to  the  glass  used  in  their  construction. 

8.  The  power  of  fusing  images  of  the  test-object  at  twenty  feet 
when  a  prism  is  placed  with  its  base  up  or  down  before  each  eye  is  next 
determined.  This  is  recorded  as  the  '''■  sursymduction'''' test  for  the  right 
or  left  e^'e.  This  test  should  not  be  employed  successively  upon  the  two 
eyes  without  some  minutes  of  rest  Lave  been  given  the  patient.  It  aids 
us  in  determining  the  relative  strength  of  the  sujDerior  and  inferior  recti 
of  the  two  eyes,  and  ofl^ers  suggestions  regarding  the  proper  muscle  to 
divide  for  the  relief  of  vertical  deviations  of  the  visual  axis  (see  test  3). 

ciency  of  the  ocular  muscles  by  prismatic  glasses  Insures  a  perfect  equilibrium  of  the  eyes 
for  any  great  length  of  time.  When  we  attempt  to  correct  this  peculiar  muscular  defect  in 
the  eye  by  weakening  the  stronger  muscle  (as  I  am  constantly  doing  with  brilliant  results) 
the  existence  of  "  latent "  insufficiency  cannot,  in  my  opinion,  be  doubted.  Unfortunately 
for  science,  we  have  as  yet  no  way  of  fully  developing  it,  as  we  do  "  latent"  hypermetropia 
by  the  aid  of  atropine. 


140  LECTUKES    ON    NERVOUS  DISEASES. 

9.  It  is  well  to  exercise  the  muscles  of  the  eye  with  prisms  before 
the  results  of  the  diplopia  tests  are  finally  recorded.  I  have  found 
tliat,  after  a  flexibilit.y  of  the  eye  muscles  has  been  obtained  by  the  aid 
of  prisms,  an  insuMiciency  of  the  internal  or  external  rectus  muscle  will 
sometimes  manifest  itself  where  it  was  not  apparent  at  first.  That  this 
is  not  simply  the  result  of  fatigue  seems  proved  by  the  fact  that  the  insuf- 
licienc}'  remains  more  or  less  apparent  during  subsequent  examinations.* 

I  have  lately  adopted  some  new  terms  suggested  b}'  m}^  friend  Dr. 
George  T.  Stevens,  in  recoixling  the  results  of  my  tests  made  to  deter- 
mine the  condition  of  ocular  muscles. 

I  quote  the  article  referred  to  in  full,  because  I  deem  it  of  great 
practical  value.     Dr.  Stevens  sa3'S : — 

"The  relations  of  the  eyes  to  each  other,  in  the  act  of  vision,  exercise  important  in- 
fluences, not  only  in  occasioning  the  condition  known  as  asthenopia,  but  in  the  causation 
of  many  other  important  nervous  disturbances. 

"If  this  statement  is  admitted,  it  will  be  evident  that  the  subject  of  irregularities  in 
the  actions  of  the  ocular  muscles  must  assume  a  greater  importance  than  when  disturb- 
ances of  equilibrium  were  regarded  as  onlj'-  occasional  factors  of  asthenopia,  and  when 
these  disturbances  were  looked  for  mainly  in  a  single  direction,  in  case  they  were  not  en- 
tirely disregarded.  It  is  true,  even  at  the  present  time,  that  'insufficiency  of  the  interni' 
is  the  only  disturbance  of  the  ocular  muscules,  excluding  strabismus  or  some  of  the  results 
of  paralysis  mentioned  in  the  majority  of  the  text-books  upon  the  eye.  Indeed,  the  im- 
portance of  even  this  defect  is  hardly  dwelt  upon  at  any  considerable  length  in  many  of 
these  works,  and  it  is  not  at  all  uncommon  for  the  oculist  to  overlook  the  condition  in  his 
practical  work. 

"  Defects  which  result  in  lasting  difficulties  and  perplexities  in  the  performance  of 
binocular  vision  are  not  to  be  ignored;  and  the  r6le  of  the  ocular  muscles  in  the  causation 
of  many  nervous  disturbances  is  undoubtedly  of  very  considerable  importance. 

"As  the  investigator  in  this  department  of  ophthalmology  proceeds  in  his  researches, 
or  attempts  to  record  his  observations,  he  is  met  by  the  fact  that  the  terms  now  in  use  are 
not  only  frequently  inaccurate  and  misleading,  but  wholly  inadequate  to  describe  many 
of  the  states  observed. 

"  To  illustrate  the  two  factors  of  the  proposition  just  made,  a  few  ordinary  conditions 
may  be  adduced : — 

"  1.  The  expressions  employed  to  designate  the  deviations  from  the  state  of  physio- 
logical equilibrium  are  often  incorrect  and  misleading. 

"The  term  'insufficiency  of  the  interni'  is  used  to  express  a  state  of  the  muscles  of 
the  eyes  which  is  shown  by  the  equilibrium  test  of  Graefe  at  reading  distance.  In  this 
test  the  images  seen  by  the  two  eyes  are  separated  by  a  prism  held  vertically,  with  its 
base  exactly  up  or  down  before  one  of  the  ej'es.  If,  under  these  circumstances,  the  images 
deviate  laterally  in  directions  opposite  to  the  two  eyes — that  is,  if  the  image  of  the  right 
eye  deviates  to  the  left,  and  of  the  left  eye  to  the  right — there  is  said  to  be  'insufficiency 
of  the  interni'  of  as  many  degrees  as  equals  the  strength  of  a  prism  which,  with  its  base 
toward  the  nose,  will  bring  the  two  images  in  a  vertical  line.  The  expression, '  insufficiency 
of  the  interni,'  in  this  relation,  is  used  to  indicate  the  fact  that  the  internal  recti  muscles 
are  'insufficient'  to  counterbalance  the  external  recti;  and  it  also  carries  the  idea 
that  the   extern!   are,   in   proportion   to   their   physiological   state,  stronger    than    the 

*  This  fact  also  confirms  the  views  expressed  in  the  previous  foot-note  (p.  13S). 


THE   TESTS   OF   VISION   AND   OCULAR   MOVEMENTS.  141 

interni,  or  that  the  interni  are,  proportionally  to  the  others,  abnormally  weak ;  tending 
thereby  to  balance  the  eyes  outward,  so  as  to  cause  an  unusual  and  excessive  demand 
upon  the  internal  recti  in  close  work. 

"  The  fact  that  a  great  many  cases,  in  which  the  equilibrium  test  of  Graefe  shows  the 
conditions  described,  are  really  'insufficiency  of  the  extern! '  and  not  of  the  interni,  must 
occur  to  any  careful  observer.  Such  a  one  will  often  find  that,  if  he  makes  his  test  of 
equilibrium  while  the  ocular  muscles  are  in  a  comparative  state  of  repose,  as  when  looking 
at  an  object  at  a  distance  of  six  metres  or  more,  he  may  find  very  marked  'insufficiency 
of  the  externi.'  He  may  even  observe  that,  if  a  screen  is  passed  before  one  of  the  eyes 
while  the  other  continues  its  gaze,  at  the  distant  object,  the  covered  eye  will  deviate  in  a 
marked  manner  inward.  If  the  screen  is  quickly  changed  to  the  opposite  eye,  he  will  see 
the  lately  covered  eye  move  outward  in  order  to  fix  the  object.  He  may  make  various 
other  tests  which  will  demonstrate  beyond  a  doubt  that  the  real  balance  of  the  eyes  is  in- 
ward, and  yet,  when  he  makes  the  test  of  the  dot  and  line  of  Graefe,  or  any  similar  test,  at 
near  point,  he  has  marked  '  insufficiency  of  the  interni.' 

"  It  is  manifestly  incorrect  to  say  of  such  a  muscular  arrangement  that  the  interni 
are  'insufficient,'  and  especially  when  by  such  a  term  it  is  generally  understood  that  the 
outer  are  the  stronger  of  the  two  opposing  sets  of  muscles. 

"Again,  in  certain  cases  of  what  is  known  as  'insufficiency  of  the  interni,'  one  of  the 
eyes  actually  deviates  inward  while  the  other  deviates  outward,  while  in  a  still  greater 
number  an  apparent  '  insufficiency  of  the  interni '  results  from  irregularities  in  the  superior 
or  inferior  recti. 

"Many  other  illustrations  of  the  truth  that  this  term  as  employed  is  misleading 
might  be  cited,  but,  without  further  expenditure  of  time  or  space,  we  may  pass  to  the  other 
factor  of  the  proposition. 

"2.  The  term  'insufficiency'  is  quite  inadequate  to  express  the  conditions  of  devia- 
tion from  the  equilibrium  as  they  may  be  observed. 

"  Graefe,  as  one  of  the  great  pioneers  in  modern  ophthalmology,  and  as  the  greatest 
authority  on  the  subject  of  muscular  asthenopia,  recognized  some  of  these  deviations,  and 
not  only  regarded  'insufficiency  of  the  interni'  as  a  condition  of  notable  importance,  but 
wrote  also  of  the  '  insufficiency  of  the  externi.' 

"  Notwithstanding  his  remarkable  observations,  much  remained  to  be  learned  in 
this  department  of  ophthalmology.  While  Graefe's  great  authority  is  to  be  fully  recog- 
nized, the  knowledge  of  these  important  conditions  may  yet  be  greatly  extended. 

"A  class  of  deviations  not  at  all  uncommon,  and  one  which  induces  great  nervous 
perplexity,  is  that  in  which  the  tendency  is  for  the  visual  line  of  one  eye  to  deviate  above 
that  of  the  other. 

"In  examining  some  thousands  of  cases  of  'insufficiencies'  I  have  found  a  very  im- 
portant proportion  of  such  tendencies.  There  is  no  term  now  in  use  which  definitely  ex- 
presses this  condition.  We  cannot  say  that  it  is  insufficiency  of  one  or  other  superior  or 
inferior  rectus,  for  it  is,  in  the  great  majority  of  cases,  impossible  to  determine  through 
what  special  influence  the  equilibrium  is  lost.  We  have  not  here,  as  in  paralysis  of  the 
muscles,  the  definite  guides  of  restricted  motions  by  which  we  may  determine  the  exact 
location  of  the  trouble.  Indeed,  the  defect  may  include  an  inclination  on  the  part  of  the 
one  eye  to  deviate  upward,  and  on  the  part  of  the  other  to  deviate  downward.  We  might, 
perhaps,  call  such  a  condition  '  insufficiency  in  a  vertical  direction,'  with  the  right  (or  left) 
line  of  vision  inclined  to  deviate  upward. 

"This  would  be  a  descriptive  and  somewhat  extended  expression.  It  would  still  be 
inaccurate,  for  it  implies  a  weakness  of  some  muscle,  when  the  actual  state  may  be  an  ex- 
cess of  tension  on  the  part  of  some  other  muscle. 


142 


LECTURES   ON   NERVOUS   DISEASES. 


"Again,  there  ma}''  and  often  does  exist  a  combination  of  faulty  tendencies  in  more 
than  one  direction.  The  eyes  may  incline  to  deviate  in  both  the  vertical  and  the  hori- 
zontal planes,  the  result  of  which  vsrill  be  a  tending  of  the  visual  lines  to  deviate  in  an 
oblique  manner.  It  must  be  apparent  that  the  term  'insufficiency'  is  inadequate  to 
express  all  these  tendencies. 

"There  may  be  some  propriety  in  using  the  expression  'insufficiency  of  the  interni' 
in  many  cases,  but  in  these  just  cited  it  would  be  impossible  for  us  to  speak  of  insufficiency 
of  this  or  that  oblique  muscle  without  more  accurate  information  than  we  are  likely  to 
possess.  Indeed,  in  the  majority  of  cases  these  muscles  may  not  be  influential  factors  in  the 
condition  described. 

"Some  term  better  adapted  to  express  just  what  is  intended,  and  nothing  more,  is 
needed.  It  is  after  much  hesitation  and  doubt  whether  a  suggestion  involving  the  use  of 
new  terms  in  connection  with  a  subject  which  has  already  engaged  the  attention  of  many 
able  investigators  might  not  be  regarded  as  needless  and  presumptuous,  that  I  have  ven- 
tured to  propose  such  an  innovation.  If,  however,  a  change  is  to  be  made  at  any  time  in 
the  classification  and  nomenclature  of  these  defects,  such  change  should  be  made  before  the 
literature  becomes  still  more  extended. 

"The  first  need  in  a  scientific  classification  of  these  muscular  defects  is  the  possession 
of  such  terms  as,  with  proper  modifications,  shall  justly  express  the  conditions  described. 

"  The  terms  which  have  already  been  employed  are  all  unsatisfactory,  and  are  not 
uniformly  employed  by  different  writers  to  describe  precisely  similar  conditions.  No  terms 
now  in  common  use  occur  to  me  as  being  in  all  respects  desirable. 

"  We  may,  therefore,  select  some  word  which  shall  convey  the  general  idea  and  which, 
with  its  proper  modifications,  will  express  our  meaning  with  specific  variations.  Such  a 
term  should  not^  like  the  word  'insufficiency,'  attempt  to  describe  the  exact  nature  of  the 
muscular  conditions,  for  this  is  often,  if  not  generally,  a  subject  of  uncertainty.  It  should 
rather  indicate  the  resultant  facts  as  shown  by  the  tendency  of  the  visual  lines  to  deviate 
from  the  physiological  equilibrium.  Nor  should  the  term  convey  the  idea  of  an  actual 
turning,  or  deviation  of  one  of  the  visual  lines  from  what  should  be  the  common  point  of 
fixation.  It  should  express  a  tendency  to  such  deviation  of  such  character  that,  should  the 
force  of  the  will  be  removed,  this  actual  turning  would  result. 

"  The  visual  lines,  in  the  conditions  under  consideration,  are  held  in  such  relations  to 
each  other  as  to  permit  of  more  or  less  perfect  binocular  vision,  but  at  an  expense  of  a  cer- 
tain excess  of  nervous  effort.  In  this  we  have  the  distinction  between  these  conditions 
and  those  known  as  strabismus;  for,  while  in  these  there  is  habitual  binocular  vision,  iu 
strabismus  there  is  habitual  diplopia,  either  conscious  or  unconscious.  It  is  true  that  a 
fusion  of  images  is  possible  in  many  cases  of  strabismus,  and  that  slight  diplopia  may  be- 
come to  a  certain  degree  a  habit,  in  the  conditions  under  consideration.  Nevertheless,  a 
condition  of  habitual  diplopia  should  in  general  be  regarded  as  distinguishing  strabismus 
from  these  conditions. 

"The  Greek  word  <j)6po^  [a  te.ndena/)  seems  to  fulfill  the  conditions  required,  and 
accurately  expresses  our  meaning  in  regard  to  this  class  of  defects.  With  this  for  our 
central  idea  we  may  easily  express  every  variety  of  tendencv  to  deviation,  as  well  as 
the  absence  of  such  tendency.  Thus  the  two  generic  terms  orthophoria  {bpBoq,  right, 
<l>6jmr,  a  tending)  and  hetcrophoria  (frfpof,  different)  would  express  respectively  a  ten- 
dency straight  forward  and  a  tendency  in  some  other  direction. 

"In  order  that  these  terms  should  yiossess  precise  signification,  the  relation  of  the 
visual  lines  to  which  they  are  applied  should.be  determined  under  the  uniform  conditions 
which  are  here  given. 

"  The  eyes  should  be  directed  toward  an  object  situated  at  a  given  distance  from 


THE   TESTS   OF   VISION   AND    OCULAE   MOVEMENTS.  143 

them,  and  the  head  should  be  in  the  position  known  as  the  '  natural'  or  '  primary'  posi- 
tion. The  most  convenient  distance  for  the  object  is  that  at  which  tests  for  refraction 
are  commonly  made;  that  is,  twenty  feet,  or  six  metres.  This  distance  is,  therefore,  chosen 
as  the  standard  for  the  determination  of  orthophoria  and  heterophoria.  The  best  object 
for  use  in  these  determinations  is  a  lighted  candle  against  a  dark  background.  It  should 
be  on  a  level  with  the  eyes  and  at  a  distance  of  twenty  feet.  If  ametropia  exists,  the  eyes 
should  be  supplied  with  suitable  correcting  glasses.  In  the  'natural  position'  the  body 
and  head  are  erect,  the  eyes  are  in  the  same  horizontal  plane,  and  the  median  line  (a 
horizontal  line  at  right  angles  with  the  line  connecting  the  two  eyes)  is  directed  exactly 
toward  the  object.  Under  these  circumstances  there  should  be  in  orthophoria  the  minimum 
of  muscular  innervation. 

"  These  conditions  being  observed,  we  may  ascertain  the  existence  of  muscular  equi- 
librium or  its  absence  by  means  of  prisms  in  the  manner  familiar  to  all  oculists. 

"  The  determination  of  the  muscular  conditions  at  near  points  will  occupy  our  atten- 
tion as  we  proceed.  It  is  to  be  remembered  that  the  results  in  such  examinations  are  by 
no  means  absolute.  Heteroi)horia  may,  like  hypermetropia,  be  partly  or  entirely  latent. 
Indeed,  as  in  actual  hypermetropia,  we  sometimes  have  apparent  myopia,  so  with  an  actual 
inward  tendency  an  apparent  outward  tendency  may  be  observed. 

"  The  different  relations  of  the  visual  lines  which  may  be  now  found  may  be  defined 
and  arranged  as  follows,  a  state  of  the  most  complete  relaxation  of  muscular  effort  attain- 
able being  always  supposed  : — 

"I.  Generic  Terms. — Orthophoria:  A  tending  of  the  visual  lines  in  parallelism. 
Heterophoria:  A  tending  of  these  lines  in  some  other  way. 

"II.    Specific  Terms. — Heterophoria  may  be  divided  into: — 

"1.     Esophoria:  A  tending  of  the  visual  lines  inward. 

"2.     Exophoria:  A  tending  of  the  lines  outward. 

"  3.  Hyperphoria  (right  or  left) :  A  tending  of  the  right  or  left  visual  line  in  a  direc- 
tion above  its  fellow. 

"This  term  does  not  imply  that  the  line  to  which  it  is  referred  is  too  high,  but  that  it 
is  higher  than  the  other,  without  indicating  which  may  be  at  fault. 

"III.  Compound  Terms. — Tendencies  in  oblique  directions  may  be  expressed  as 
hyper esophoria,  a  tending  upward  and  inward  ;  or  hyperexophoria,  a  tending  upward  and 
outward.     The  designation  'right'  or  'left'  must  be  applied  to  these  terms. 

"  In  recording  the  respective  elements  of  such  compound  expressions  I  have  employed 
the  sign  L_.  For  example,  if  it  is  desired  to  indicate  that  the  right  visual  line  tends  above 
its  fellow  3°,  and  that  there  is  a  tending  inward  of  4°,  the  facts  are  noted  thus:  Eight 
hyper  esophoria,  3°   L.  4°. 

"  In  the  absence  of  any  means  of  producing  a  uniform  state  of  relaxation  of  the  long 
ocular  muscles,  such  as  we  possess  in  atropine  for  the  ciliary  muscles,  we  must  resort  to 
every  known  device  to  ascertain  as  nearly  as  possible  the  true  relations  of  the  muscles. 
Methods  other  than  that  of  measuring  the  deviation  when  diplopia  is  produced  should, 
however,  be  regarded  as  auxiliary,  and  the  record  of  ortho-  or  heterophoria  should  be 
made  from  the  diplopia  test. 

"  The  powers  of  the  different  pairs  of  muscles  to  overcome  prisms  should  next  be  de- 
termined. Some  confusion  has  existed  in  the  use  of  terms  to  express  this  power.  Thus, 
the  words  adduction  and  abduction  have  been  employed  by  Graefe  and  succeeding  writers 
to  express  the  power  of  the  eyes  to  overcome  respectively  a  prism  with  its  base  out  or  in. 
They  have,  however,  been  employed  to  express  this  power  both  when  the  object  of  fixa- 
tion has  been  at  a  considerable  distance,  and  when  at  the  ordinary  reading  distance. 

"  The  same  words  are  also  used  to  express  the  limits  of  excursion  of  the  eyes  outward 
or  inward  in  the  act  of  fixation. 


144  LECTURES   ON  NERVOUS  DISEASES. 

"  The  words  convergence  and  divergence  have  similarly  been  employed  to  express 
different  classes  of  phenomena.  As  the  words  adduction  and  abduction  are  necessary  to 
express  the  power  of  moving  outward  and  inward  of  either  eye  singly,  and  as  the  terms 
convergence  and  divergence  must  in  all  cases  imply  the  approach  or  the  separation  of  the 
axis  of  the  two  eyes,  whether  in  the  act  of  overcoming  a  prism  or  otherwise  there  might 
be  an  advantage  in  employing  the  word  convergence  to  indicate  the  highest  degree  of  power 
of  blending  images  at  a  distance  of  twenty  feet  when  a  prism  with  its  base  out  is  inter- 
posed; and  the  term  divergence  to  indicate  the  limit  of  power  to  overcome  a  prism  with  its 
base  in.  This  latter  would  also  be  less  liable  to  objection  for  the  reason  that,  while  each  eye 
is  habitually  directed  in  abduction  and  adduction,  the  two  are  rarely  by  voluntary  effort 
caused  to  diverge  except  by  the  influence  of  a  prism.  The  fact,  however,  that  Graefe  in 
his  classic  treatise  on  muscular  asthenopia  employed  the  words  abduction  and  adduction 
to  indicate  the  abilitj'^  to  overcome  prisms  must,  beyond  a  doubt,  determine  the  point,  and 
these  words  should,  therefore,  represent  the  diverging  and  converging  power  with  prisms. 
The  standard  of  distance  should,  however,  be  uniform  with  that  for  the  test  for  ortho-  and 
heterophoria. 

"  It  often  happens  that  images  can  be  united  when  a  prism  is  placed  before  an  eye 
with  its  base  up  or  down,  but  that  diplopia  is  produced  if  the  prism  is  reversed,  or  if  it  is 
placed  in  the  first  position  before  the  other  eye.  In  other  words,  the  tendenc}'^  of  one 
visual  line  being  higher  than  the  other,  the  power  to  blend  images  is  greater  when  the 
prism  is  placed  in  one  than  when  placed  in  the  opposite  direction. 

"  This  condition  is  one  of  great  importance,  and  no  examination  of  muscular  equi- 
librium should  be  regarded  as  complete  in  which  its  presence  or  absence  is  not  determined. 
The  ability  to  overcome  a  prism  with  its  base  down  may  be  called  sursumduction,  and  the 
eye  before  which  the  prism  is  placed  is  indicated  by  the  word  'right'  or  'left.' 

"It  remains  to  consider  the  relations  of  the  muscles  when  the  eyes  are  directed  to 
objects  at  the  usual  reading  distance. 

"These  relations  maj'  be  uniform  with  those  manifested  at  a  distance,  or  they  may 
vary  in  degree  or  in  the  direction  of  greatest  apparent  energj'.  To  these  conditions  it 
might  at  first  appear  best  to  apply  the  familiar  terms  '  insufiiciency  of  the  interni'  or 
'externi.' 

"The  objections  are  that  the  terms  have  already  been  employed  to  express  the  rela- 
tions of  the  eyes  in  accommodation  and  also  in  repose,  and  that  only  two  of  many  con- 
ditions can  be  described. 

"The  relations  of  the  visual  lines  in  accommodation  do  not  alwaj's  depend  upon  the 
comparative  strength  or  weakness  of  the  opposing  muscles,  but  upon  a  peculiar  state  of 
innervation  of  the  muscles. 

"The  habit  of  maintaining  an  excessive  tension  upon  the  outer  muscles  in  order  to 
overcome  esophoria  frequently  manifests  itself  in  the  near  test  as  '  insufficiency  of  the  in- 
terni.' 

"  These  considerations  render  it  desirable  that  a  uniformity  in  the  descriptive  terms  for 
the  near  and  distant  tests  should  be  maintained.  The  terms  already  employed  for  distance 
may,  therefore,  be  properly  used  if  the  modifying  phrase  'in  accommodation'  is  added. 
Thus  we  should  have  for  insufficiency  of  the  interni  exophoria  vi  accommodation,  etc. 

"  The  relations  of  the  ocular  muscles  should,  as  Graefe  has  shown,  occupy  a  prominent 
place  in  the  record  of  all  examinations  of  the  eyes  for  asthenopia  or  kindred  troubles. 

"  If  the  system  of  words  here  introduced  at  first  appears  to  be  superfluous,  and,  there- 
fore, unnecessary,  a  careful  consideration  of  the  subject  will  be  likely  to  convince  a  candid 
observer  that  new  and  more  definite  terms  are  needed  to  convey  uniform  meanings,  and  to 
express  more  conditions  than  are  described  by  terms  now  in  use.     The  terms  here  proposed 


ASTIGMATISM   AND   ESTIMATION   OF   THE   VISUAL   FIELD.       145 

are  explicit  in  meaning,  and  the  system,  by  arranging  the  various  deviating  tendencies 
into  classes,  suggests  to  the  examiner  the  conditions  concerning  which  he  should  inform 
himself." 

Thus  ffir,  then,  in  the  examination,  our  record  page  in  blank  would 
stand  as  follows  : — 

Name Residence Date 

(  R.  =  - corrected  by glass. 

■  i  L_  ^^   M ^,  ^,  ^  ^       ^^ 

Astigmatism "  "    

Esophoria in  accommod 

Exophoria in  accommod 

Abduct Adduct 

Hyperphoria,  R L 

Sursumduct,  R L 

Reading  power  at  fourteen  inches,  corrected  by glasses. 

VISUAL   FIELD.  OPTHALMOSCOPE. 


All  the  data  indicated  for  record  in  this  table,  excepting  the  esti- 
mation of  the  degree  of  astigmatism  and  the  outline  of  the  visual  field, 
have  been  referred  to,  and  the  tests  for  each  have  been  given  with  some 
detail. 

The  esiimation  and  correction  of  astigmatism  is  a  difficult  matter  for 
a  novice,  and  sometimes  for  an  expert.  It  will  l)e  better  understood  by 
reference  to  and  close  study  of  the  standard  text-books  on  ophthal- 
mology. Moreover,  the  ophthalmoscope  is  often  required  to  properly 
estimate  the  degree  and  kind  of  astigmatism  which  exists.  I  would  say, 
in  passing,  that  a  high  degree  of  astigmatism  should  never  he  disregarded 
or  left  uncorrected,  especially  if  present  in  connection  with  abnormal 
nervous  phenomena.  It  is  a  very  common  cause  of  headache  and  as- 
thenopic  symptoms. 

In  estimating  the  visual  field,  nj\  instrument  specially  designed  for 
that  purpose  (the  perimeter)  greatly  simplifies  the  step,  and  gives  us  at 
the  same  time  an  accurate  representation  of  its  outline  for  subsequent 
reference.  A  drawing  can  be  roughly  made,  however,  of  the  visual  field 
of  any  patient,  by  means  of  a  blackboard  and  a  piece  of  chalk,  through  a 
simple  method  described  in  most  of  the  text-books.  In  some  nervous 
cases  it  is  very  desirable  that  a  register  of  the  visual  field  be  taken  from 
time  to  time  and  preserved  for  reference. 

10 


146 


LECTURES     ON     NERVOUS     DISEASES. 


Now,  when  we  h;ive  carofully  examined  ouv  patient  respecting  all 
the  data  indicated  in  the  preceding  table,  are  we  safe  in  passing  an 
opinion  respecting  the  condition  of  the  eyes?  I  would  again  say, 
"No." 

We  have  now  reachcfl  a  point  where  we  shonld  admiiusfer  atropine 
to  the  patient.  I  usuall}'  employ  a  solution  of  gr.  iv  of  sulphate  of  atro- 
pine to  an  ounce  of  distilled  water.  This  can  be  kept  constantly  in  3'onr 
otlice  in  a  i)hial  with  a  rubber-top  dropper  substituted  in  place  of  a  eoi-.k. 
A  drop  or  two  in  each  eye  will  suflice  in  most  subjects  to  dilate  the  pupil 
widely  and  to  paralyze  the  power  of  accommodation  of  vision  for  near 
objects  in  about  three  hours.  In  occasional  instances  it  becomes  neces- 
sary to  keep  the  patient  under  its  influence  for  several  days,  but  tiiis  is 
not  the  rule. 

It  is  well  to  caution  the  patient,  after  using  this  drug,  that  he  may 
possibly  sutler  from  the  sunlight,  and  that  colored  glasses  will  relieve  him 
of  this  annoyance.  It  is  also  best  to  tell  him  that  his  vision  may  become 
very  blurred  for  distant  objects  in  case  he  is  far-sighted;  and  that,  in  any 
case,  he  will  he  unable  to  read  or  to  write  by  the  aid  of  vision  without 
glasses  for  several  days.  I  have  known  hypermetropic  patients  to  be- 
come greatly  alarmed  at  the  rapid  loss  of  vision  which  has  followed  the 
use  of  atropine ;  all  of  which  could  easily  have  been  avoided  had  they 
been  prepared  for  it  by  timely  words  of  explanation.  It  is  always  well 
to  explain  to  far-sighted  subjects  the  ditference  between  "manifest"  and 
"latent"  hypermetropia,  and  to  make  them  intelligent  as  regards  the 
effect  of  atropine  upon  the  "focusing"  muscle  before  you  administer  it. 
If  they  are  forced  by  their  business  to  use  their  eyes  for  near-work  while 
under  the  influence  of  atropine,  a  pair  of  cheap  glasses  ma^^  be  given 
them  for  temporary  use  while  under  its  influence. 

I  cannot  impress  too  strong]}"  upon  you  the  necessity  of  using  atro- 
pine upon  a  patient  (if  young)  for  diagnostic  purposes  when  an  error  of 
refraction  or  of  accommodation  is  suspected.  Personally,  I  do  not  regard 
an  examination  as  complete  without  it.  It  solves  the  question  of  the  pres- 
ence of  "latent"  hypermetropia — a  very  common  defect  and  a  very  im- 
portant one  (from  the  standpoint  of  the  neurologist)  if  allowed  to  go 
unrecognized.  It  reveals  the  existence  of  a  previous  ciliary  spasm. 
It  often  arrests  headache  as  if  by  a  magic  touch,  and  solves  the  nervous 
origin  of  many  other  similar  symptoms. 

Patients  who  boast  of  their  acuteness  of  vision,  and  who  apparently 
justify'  their  statement  by  reading  test-type  at  a  distance  without  the  aid 
of  glasses,  are  often  astonished  and  sometimes  alarmed  at  the  immediate 
loss  of  this  power  which  is  brought  about  by  the  use  of  atropine.  This 
surprise  is  heightened  when  (bv  the  use  of  proper  lenses)  their  power  of 
vision  for  distance  is  immediately  restored,  and  they  become  conscious 


LATENT  ERRORS  OF  REFRACTION.  147 

for  the  first  time  of  the  imiscuhir  efl'ovt  which  they  have  been  compelled 
in  the  psist  to  exert  in  order  to  see  witliout  them.  I  shall  never  forget,  per- 
sonally, the  sensation  which  I  experienced  of  "  seeing  withont  effort "  when 
a  latent  h3'permetropia  was  discovered  in  ni}'  own  eye,  and  corrected  by 
glasses. 

These  experiences  are  well-known  facts  among  ocnlists,  hnt  to  the 
profession  at  hxrge  they  often  occasion  as  ninch  of  a  surprise  as  to  the 
patient. 

I  conld  point  to  case  after  case  in  my  own  practice  where  the  cause 
of  neuralgic  attacks,  excruciating  headache,  vomiting,  extreme  nervous- 
ness, and  many  other  symptoms  (not  apparently  connected  with  eye-de- 
fect) would  have  remained  unrecognized  if  atropine  had  not  been  em- 
ployed. There  is  a  rule  given  by  most  oculists — viz.,  to  give  to  a  hyper- 
metropic patient  the  strongest  convex  glass*  with  which  he  can  comfortably 
read  the  normal  test-type  (xx)  at  a  distance  of  twenty  feet.  It  is  impos- 
sible in  many  cases  to  decide  this  fact  without  atropine  or  an  ophthal- 
moscope. The  former  method  is  un(iuestionably  the  most  accurate  one, 
because  the  accommodation  of  the  oculist,  as  Avell  as  that  of  the  patient, 
has  to  be  excluded  in  the  latter;  and  it  has  the  advantage,  moreover, 
that  it  can  be  employed  by  the  general  practitioner  as  well  as  by  the 
specialist.  "I* 

Now,  after  the  patient  returns  to  you  with  widely  dilated  pupils,  you 
should  carefully  repeat  each  step  of  the  piremous  examination.  You 
should  record  the  results  of  these  tests  and  then  compare  them  with  those 
obtained  before  atropine  was  employed.     If  the  eye  is  a  normal  one,  the 

20 
vision  will  be  —  after  atropine  has  been  used,  as  it  was  on  the  first  ex- 

XX 

amination ;  but,  when  an  error  of  refraction  or  accommodation  exists, 
changes  of  a  greater  or  less  degree  may  be  noted.  You  may  find,  more- 
over, that  the  power  of  adduction  and  of  abduction  of  the  eye  will  be  mod- 
ified in  some  patients  by  the  action  of  the  drug  upon  the  accommodation  of 
vision,  and  that  a  ditferent  degree  of  muscular  insufficiency  ma}^  be  detected. 
You  can  now  decide  intelligently  as  to  the  glass  which  is  best  adapted  to 
restore  vision  for  distant  and  near  objects  in  each  eye  of  the  patient,  and 
you  are  prepared  to  advise  the  patient  respecting  the  use  of  the  glasses 

*  The  advisability  of  a  full  correction  by  glasses  of  existing  hypermetropia  can  only  be 
decided  after  the  condition  of  the  patient,  his  age,  his  susceptibility  to  reflex  irritation  from 
eye-strain,  etc.,  have  been  carefully  considered.  It  is  not  usually  advisable  to  force  a 
young  subject  to  wear  a  glass  which  fully  corrects  the  latent  hypermetropia.  I  am  in  the 
habit  of  correcting  all  latent  hypermetropia  in  excels  of  one  dioptre. 

t  Personally,  I  have  of  late  discarded  the  ophthalmoscope  as  a  means  of  estimating 
errors  in  refraction,  except  in  children  and  feeble-minded  persons.  It  cannot  always  be 
relied  upon,  even  in  the  hands  of  an  expert,  for  this  special  object. 


148  LECTUKES   ON  NEKVOUS   DISEASES. 

selected.  You  can  decide  also  respecting  the  question  of  the  utilit}'  of 
prisms  or  of  tenotomy  if  the  patient  has  marked  insufficiency  of  the 
muscles.  You  can  judge  more  accurately  respecting  the  proper  angle  of 
the  prism  retjuired  in  case  tlieir  use  is  indicated.  I  would  caution  3'ou, 
however,  agaiust  deciding  this  latter  point  before  the  error  of  refraction 
(if  such  exists)  is  corrected^  and  not  until  the  "diplopia  tests" 
have  been  emplo>'cd,  after  such  lenses  as  are  required  to  correct  it  have 
been  placed  before  the  patient's  eyes.  I  have  seen  patients  who  gave 
evidence  of  marked  insufficiency  (5°  to  8°),  when  the  refractive  error  was 
inicorrected,  exhibit  no  such  defect  when  glasses  which  corrected  that 
error  were  worn.  Prisms  in  such  a  case  would  inflict  injur}^  upon  the 
patient  rather  than  afford  relief. 

In  closing,  I  would  remark  that  views  which  I  have  advanced  respect- 
ing the  dependence  of  abnormal  nervous  phenomena  upon  eye-defect  are 
not  new.  They  are  in  antagonism,  however,  to  those  of  some  authors, 
and  have  been  more  or  less  actively'  combated  of  late,  especially  in  regard 
to  eye-defect  as  a  cause  of  chorea  and  epilepsy.  I  do  not  think  the  re- 
lationship between  "eye-strain"  and  attacks  of  headache  or  neuralgia 
can  be  denied,  although  it  is  only  hinted  at  b}"  Anstie  and  is  omitted 
by  most  authors  who  have  written  on  the  causes  and  cure  of  these  dis- 
tressing maladies.  Some  of  our  best  neurologists,  as  well  as  most  oculists, 
are  now  investigating  with  renewed  interest  not  onl}-  the  ametropic  con- 
ditions of  the  eye,  but  also  the  ej-e  with  "insufficient"  muscles.  Facts 
are  being  daily  substantiated  be^'ond  dispute  which  met  with  ridicule 
some  3'ears  since.  Ever^^  day,  in  my  own  experience,  I  am  strongl}'^  im- 
pressed with  the  curative  effects  of  glasses  and  partial  tenotomies  of  the 
ocular  muscles  in  various  forms  of  functional  nervous  disturbances.  In 
my  opinion,  the  neurologist  of  to-day  who  fails  to  familiarize  himself 
thoroughly  with  the  examination  of  the  eye  omits  an  evident  line  of 
dut}'  both  to  himself  and  his  patients.  No  neurologist  can  send  all  of 
his  cases  to  an  oculist  for  an  opinion,  and,  even  if  he  could  do  so,  he 
should  at  least  be  able  to  verify  the  opinion  thus  gained  respecting  the 
refractive  errors  found  and  the  state  of  the  eye-muscles.  He  requires 
a  case  of  lenses  and  prisms  in  his  office  as  much  as  an  electrical  outfit, 
and  he  should  know  how  to  use  both — the  one  as  an  aid  in  diagnosis, 
and  the  other  as  a  means  of  cure.  Personally,  I  have  come  to  regard 
the  examination  of  any  patient  sent  to  me  as  incomplete  until  I  have 
tested  the  state  of  refraction  and  accommodation,  and  examined  with 
care  the  condition  of  the  ocular  muscles.  This  view  has  not  been 
hastily  formed,  and  my  daily  experiences  confirm  me  in  it.  I  believe 
the  time  will  come  when  the  tests  employed  in  eye-examinations  will 
rank  in  importance  in  neurology  with  the  knee-jerk  test,  which  for 
generations,  as  Gowers  remarks,  simply  "amused  school-boys." 


THE   USE   OF   THE   OPHTHALMOSCOPE. 


149 


The  OrHTHALMOSCOPE. — In  connection  witli  the  eye,  it  may  be  well 
to  mention  the  instrument  wliich  is  employed  to  detect  abnormalities  of 
that  organ,  viz.,  the  ophthalmoscope. 

All  forms  of  this  instrument  consist  (1)  of  a  concave  mirror  which 
is  perforated  at  its  centre,  in  order  that  the  observer  may  look  directly 
into  the  illumined  field;  (2)  a  series  of  lenses  by  which  it  is  possible  to 
correct  errors  of  refraction  in  the  eye  of  the  patient  or  observer;  (3)  a 
bi-convex  lens,w'hicli  brings  tlie  deeper  parts  of  the  eye  into  prominence, 
and  enables  the  observer  to  inspect  them  minutely. 

Hutchinson  (as  quoted  by  Hamilton)  gives  some  concise  and  prac- 
tical suggestions  respecting  the  use  of  this  instrument,  which  will  bear 
repetition.     He  says: — 


Fig.  40 — The   Ot'HTHALMOscoPE.     (Loring's  Pattern.) 

"  Plaving  placed  the  patient's  head  in  such  a  manner  that  the  light  (a 
lamp,  candle,  or  gas-light)  is  on  a  level  with  his  temple,  and  slightly  be- 
hind it  and  his  face,  as  a  consequence,  in  shadow,  the  observer  sits  in 
front  and  applies  the  ophthalmoscope  mirror  to  his  own  eye.  He  should 
keep  both  eyes  open  that  he  may  see  w-here  the  light  falls,  and  then  move 
the  mirror  until  the  light  falls  full  upon  the  pupil  of  his  patient.  In  a 
moment  he  will  perceive  the  first  fact  which  this  instrument  reveals,  thnt 
the  fundus  is  not  black,  as  it  has  always  appeared  to  be  before,  but  that 
it  is  of  a  brilliant  fire-red.  He  will,  however,  see  nothing  of  the  fundus 
distinctly,  only  a  general  reflex      Now  at  this  point  the  student  must 


!")(•  LECTURES   OX    NERVOUS   DISEASES. 

stop  :i\vhiK'  iiiul  use  his  mirror  to  inspect  first  the  transpareuey  of  the 
eornea.  and  next,  that  of  the  lens  and  vitreous,  and  to  do  this  he  must 
make  the  patient  move  his  e^e  in  various  directions.  After  a  little  prac- 
tice he  will  be  able  to  nianaoe  his  li<;ht  well,  and  to  throw  it  with  pre- 
cision wherever  he  may  wish,  and  to  keej)  it  steadily  on  any  given  part. 
At  a  first  lesson,  he  mny  even  witli  advantage  [)ractice  for  awhile  l)v  illu- 
minating the  second  button  of  the  patient's  waistcoat.  Tact  in  directing 
the  light  having  been  obtained,  we  may  now  proceed  furtlier.  Instruct 
the  patient  to  look,  not  full  in  your  lace,  but  over  one  shoulder;  if  you 
are  inspecting  his  right  eye,  over  your  left  slioulder.  You  will,  when  he 
does  this,  notice  at  once  that  the  tint  of  the  light  reflected  from  the 
fundus  is  changed,  that  it  is  no  longer  fire-red,  but  canary  yellow.  The 
reason  of  this  is,  that  a  different  part  of  the  fundus  is  exposed  to  view, 
that,  namely,  of  the  optic  disk  itself,  which- is  much  lighter  in  color  than 
the  rest.  The  area  of  yellow  is  very  large, — occupies,  indeed,  the  whole 
of  the  field,  while  we  know  that  the  disk  itself  is  very  small.  Tiiis  proves 
that  the  objects  thus  distinctly  seen  are  immensely  magnified.  Magnified 
by  what?  By  the  patient's  own  eyQ,  which,  as  we  have  said,  is  equivalent 
to  a  lens  of  one-inch  focus. 

"Hitherto  we  have  seen  nothing  distinctly,  but  if  the  observer  now 
brings  his  head  very  close  to  the  patient's  face,  he  will  be  able  with  more 
or  less  facility  to  observe  the  details  of  the  bottom  of  the  eye,  the  trunks 
of  the  vessels  of  the  retina,  the  optic  disk,  etc.  What  he  sees  is  now 
equivalent  to  t3'pe  looked  at  through  a  one-inch  lens,  placed  exactly  one 
inch  in  front  of  it." 

In  the  ophthalmoscope  now  generall}'  employed,  a  revolving  disk 
containing  a  series  of  lenses  is  placed  behind  the  mirror.  These  are  in- 
tended for  the  purpose  of  correcting  any  error  of  refraction  in  the  eye  of 
the  observer  or  patient.  It  is  important  that  such  error  be  determined 
first  with  accuracy  and  properly  corrected,  before  the  fundus  is  examined. 

The  ophthalmoscope  is  an  important  and  valuable  aid  to  those  who 
are  skilled  in  its  use  in  detecting  changes  in  the  deep  parts  of  the  eye, 
chiefl}'  those  of  the  optic  nerve  and  the  vessel  of  the  retina,  b^-  means  of 
the  sense  of  sight. 

Dr.  William  C.  Ayres  has  lately  published  in  The  American  Journal 
of  the  Medical  Sciences  (1881)  an  exceedingly  valuable  and  complete 
article  upon  this  branch  of  diagnosis 

By  means  of  the  ophthalmoscope  the  neurologist  determines  the 
presence  or  absence  of  a  neuro-retinitis,  or  a  ■•  choked  disk- "  as  it  is  called, 
which  is  peculiarly  suggestive  of  some  brain  lesion,  that  is  creating  a 
gradually  increasing  pressure  within  the  cavity  of  the  skull.  Again,  the 
vessels  of  the  retina  are  derived  from  the  same  source  as  those  of  the 
brain  ;  hence  changes  in  the  one  are  liable  to  be  associated  with  similar 
chanues  in  the  other. 


THE    EYELIDS    AND    MOUTH    IN    DIAGNOSIS.  151 

The  Eyelids. — These  may  afford  valuable  aid  in  diagnosis.  The 
upper  lid  sometimes  drops  over  the  eyeball  and  cannot  l»e  I'aised,  con- 
stituting- the  condition  termed  '•  ptosis."  This  indicates  a  paralysis  of 
the  third  cranial  nerve.  Again,  when  the  facial  nerve  is  paralyzed,  the 
eyelids  of  the  affected  side  cannot  be  closed.  Puliiness  of  the  lower 
eyelid,  especially  in  the  morning  after  rising,  suggests  the  possibility  of 
kidney  disease.  Alcoholic  patients  often  exhibit  a  quiver  of  the  mus- 
cular tibres  of  the  e3-elids.  Spasm  of  the  lids  produces  the  peculiar 
winkiug  so  often  seen  in  St.  Vitus'  dance  and  other  nervous  affections. 
In  imbeciles  and  cretins  the  lids  are  often  obliquel}^  placed. 

The  expression  of  the  eye  is  influenced  to  a  large  extent  by  the  e3'^e- 
lids  and  may  often  be  characteristic  of  certain  nervous  diseases.  Melan- 
choliacs  exhibit  the  downcast  eye.  Maniacs  may  look  excited,  suspicious, 
or  distrustful.  A  vacant  stare  is  often  present  in  dementia.  Some  forms 
of  brain  disease  exhibit  in  the  eye  an  air  of  exaltation.  Masturbators 
seldom  direct  their  gaze  at  the  questioner,  but  look  furtively  about  as  if 
to  avoid  scrutiny. 

The  Mouth. — The  lips  are  sometimes  pai-alyzed.  The  pronunciation 
of  the  labials  is  then  rendered  indistinct  or  impossible,  and  a  facial  de- 
formity is  also  created.  The  various  diseases  in  which  the  mouth  is 
affected  may  be  considered  separately  with  advantage. 

A.  In  BeU'i^  pared tj six  the  lips  are  rendered  incapable  of  moveinent 
on  one  side  only  and  the  mouth  is  drawn  toward  the  opposite  side  by 
muscles  w^hich  are  no  longer  antagonized,  on  account  of  the  facial 
paralysis.  The  act  of  whistling  is  rendered  impossible,  because  ''i)ucker- 
ing"  of  the  lips  requires  a  contraction  of  the  symmetrical  muscles  of  the 
face.  The  saliva  is  no  longer  retained,  and  the  patient  "drools."  All 
expressions  except  that  of  repose  are  those  of  a  face  alive  on  one  side 
and  dead  and  motionless  on  the  other ;  hence,  they  would  be  particularly 
grotesque  and  striking  (were  it  not  so  frightful  and  distressing)  even  to 
a  casual  observer. 

In  those  rare  cases  where  the  facial  nerve  of  both  sides  is  impaired, 
s^-mptoms  similar  to  those  mentioned  above  exist,  except  that  the  tongue 
has  its  normal  capabilities  of  movement,  save  in  the  perfect  articulation 
of  the  labial  consonants  only,  and  that  a  complete  absence  of  uxcial  ex- 
pression is  present. 

Certain  rules,  which  prove  of  value  in  making  a  diagnosis  of  the  seat 
of  the  exciting  cause  of  the  condition  have  been  given  in  the  preceding 
chapter  (p.  85).  They  are  based  entirely  upon  anatomical  facts,  and  are 
therefore  very  important,  because  they  admit  of  no  exceptions: — 

B.  The  lips  and  tongue  are  particularly  affected  also  in  that  disease 
of  the  medulla  called  Duchenne''s  disease  (glosso-labio-laryngeal  pa- 
ralysis).     So  marked  is  this  loss  of  power,  in  severe  cases,  that  a  most 


152 


LECTUKES   ON   NERVOUS   DISEASES. 


characteristic  facial  defonnitv  is  iiidiieed.  As  tliis  tliscase  is  commonly 
bilateral,  the  lips  usually  lian<>-  apart  from  each  other  and  cannot  be 
approximated.  The  tongue  lies  trembling  and  immoval)le  in  the  floor  of 
the  mouth,  if  the  paralysis  be  complete;  but  if  paresis  only  exists,  it  can 
be  imperfectly  protruded  with  difficult}^  and  is  tremblingly  and  slowly 
retracted.  If  the  paralysis  be  unilateral,  the  healthy  side  of  the  tongue 
becomes  full  and  prominent,  in  comparison  with  the  affected  side,  when 
called  into  action.  Speech  and  mastication  are  seri(^usly  eml»arrassed. 
The  saliva  is  constantly  expectorated,  because  swallowing  is  performed 
with  extreme  difficulty. 

G.     The  facial  muscles,  as  well  as  the  tongue,  exhibit  n   peculiar 
tremor  in  paralytic  dementia.     Small  bundles  of  fibres  comi)osing  parts 


Fig   41. — Bell's  Paralysis.     (After  a  Sketch  from  Life  by  the  Author.) 

of  the  tongue,  or  the  delicate  muscles  of  the  face,  are  thrown  into  non- 
rhythmical  contractions  by  emotion,  or  the  performance  of  any  voluntary 
movement,  as  when  showing  the  tongue  or  teeth.  These  fibrillary  tremors 
ma}^  sometimes  exist  even  in  the  quiescent  state  of  the  muscles.  The 
tongue  occasionally  exhibits  coarser  movements  of  a  convulsive  character. 
Late  in  the  disease  it  may  become  atrophied  or  shriveled. 

The  effects  of  this  form  of  tremor  upon  speech  are  aggravated  l)v  an 
imi>erfect  coordination  of  the  muscles  of  the  tongue  and  lijis.  which  is 
simultaneously  developed.  Long  or  difficult  words  are  omitted  in  con- 
versation })y  these  patients  in  a  half-unconscious  way,  and  the  terminal 
syllable  of  other  words  is  commonly  left  off.  The  speech  becomes  thick, 
and  of  a  tremulous  character.     The  shortest  words  possil)le  are  employed 


THE   LIPS,    GUMS,    TEETH,    AND   TONGUE.  153 

by  the  patient  to  convey  his  ideii.s.  A  distinct  pronnnciation  of  conso- 
nants and  polysyllabic  words,  such  as  "constitution,"  "intallibility," 
"prognostication,"  etc.,  is  impossible;  hence,  a  test  is  thus  artbrded 
between  carelessness  of  utterance  and  a  physical  inability  to  articulate. 

An  unnatural  quietude  of  the  muscles  of  the  face  and  a  slight  dis- 
parity of  the  pupils  are  prominent  features  of  its  stage  of  development. 

It  is  well  to  note,  in  this  connection,  a  test  which  is  of  some  value 
in  deciding  as  to  the  existence  of  this  special  form  of  disease.  Extend 
the  patient's  fingers  and  place  them  between  your  own,  and  a  delicate, 
"  parchment-like  "  fremitus  will  be  felt,  which  is  due  to  an  otherwise  imper- 
ceptible tremor  of  the  hand  muscles. 

D.  The  lips  participate  to  a  marked  degree  in  severe  types  o^  facial 
spasm.  In  the  clonic  form  of  the  muscles  on  one  side  of  the  face,  are 
violently  contracted  and  as  suddenly  relaxed.  The  eye  is  commonly 
allected  simultaneously  with  tlie  angle  of  the  mouth.  The  spasms  are 
marked  by  distinct  paroxysms,  whose  duration  varies  from  a  few  seconds 
to  an  hour  or  so.  If  the  spasm  is  of  atonic  variety,  mastication  and 
articulation  are  interfered  with,  and  the  paroxysms  are  of  longer  duration. 

It  is  always  well  to  search  carefully  for  carious  teeth  in  these  cases ; 
but  the  spasms  may  be  due  to  cold,  wounds,  injuries  to  the  trigeminal 
nerve,  or  chorea. 

E.  The  lips  may  indicate  some  form  of  defect  in  the  heart's  action 
if  blue  or  purple  in  color. 

Scars  at  the  corners  of  the  mouth  are  strongly  suggestive  of  previous 
syphilitic  ulceration,  a  point  of  importance  in  the  treatment  of  some 
forms  of  nervous  disease. 

F.  The  gums  should  always  be  inspected.  If  pale,  ana?mia  exists. 
If  blue  along  the  line  of  junction  with  the  teeth,  lead  poisoning  is 
present.  If  the  teeth  are  loosened  and  the  gums  are  soft  and  bleed  easily, 
mercurial  poisoning  may  be  suspected ;  this  is  rendered  positive  if  the 
breath  has  the  "mercurial  odor"  and  the  saliva  is  excreted  in  very  large 
quantities.  Various  cachexias,  phosphorus  poisoning,  purpura,  and 
scurvy,  produce  marked  and  often  characteristic  changes  in  the  gums. 

O.  The  teeth  may  afford  much  valuable  information  respecting  the 
possibility  of  hereditary  s^'philis.  Hutchinson  has  described  the  char- 
acteristics of  such  teeth  with  accuracy  and  detail.  It  is  impossible  to 
quote  his  deductions  here,  but  the  peculiarities  of  syphilitic  teeth  are 
now  generally  well  recognized,  and  are  often  a  valuable  aid  to  the  neu- 
rologist, both  in  diagnosis  and  treatment. 

H.  The  tongue.  Some  diagnostic  points  regarding  the  tongue  have 
been  touched  upon  already.  When  the  face  exhibits  any  form  of  pa- 
ralysis, it  should  be  always  carefully  noted  if  the  tongue  exhibits  fibril- 
lary tremors;  also  wliether  it  can  be   protrudc<l  in  a  straight  line  and 


154 


LECTUllES   ON   NERVOUS   DISEASES. 


mcned  Ireely  in  uU  [)ossil)le  directions.  In  testing  speeclj  tliose  words 
should  be  employed  that  require  the  normal  power  of  movement  of  the 
lips  (the  labials)  and  of  the  tongue  (chiefly  the  consonants).  It  should 
be  also  noted  whether  the  words  are  clearly,  rapidly,  and  distinctly 
articulated,  or  if  the  utterance  of  words  is  slow,  thick,  or  slurred. 

Ragged  edges  in  the  tongue  indicate  epilepsy,  because  it  is  fre(piently 
bitten  during  the  paroxysms. 

Imperfect  mastication  of  food  and  ditliculty  in  swallowing  may  be 
due  to  loss  of  power  in  the  tongue. 

A  ''furred  condition"  of  one  lateral  half  of  the  tongue  indicates 
some  irritation  of  the  In-anches  of  the  fifth  cranial  nerve;  hence,  the 
presence  of  decayed  teeth,  diseases  of  the  gums,  or  the  maxillary  bones, 
etc.,  should  be  carefully  searched  for.  The  tongue  may  be  paralyzed  on 
one  side  or  on  both.  This  condition  is  not  infreciuently  due  to  hemor- 
rhage, softening,  or  tumors  of  the  brain,  and  it  occurs  in  connection  with 
embolism  or  the  general  paralysis  of  the  insane. 


i*N, 


Fig.  42 — Syphilitic  Teeth.     (Hutchinson.) 


Spasm  of  the  tongue  may  be  perceived  in  connection  with  chorea, 
epilepsy,  hysteria,  facial  spasm,  and  as  a  result  of  slight  compression  or 
irritation  of  the  hypoglossal  nerve.  Fibrillary  tremors  of  the  tongue  are 
often  encountered  in  patients  afflicted  with  paralytic  (lementia. 

/.  The  soft  palate  may  be  implicated  when  the  facial  nerve  is  injured 
above  the  origin  of  the  petrosal  nerves.  It  is  important  to  examine  the 
palate,  therefore,  whenever  Bell's  paralysis  exists,  since  the  seat  of  the 
exciting  cause  may  be  decided  by  it.  It  may  participate  also  in  atroi)hic 
changes. 

The  Ear. — Deposits  of  urate  of  soda  are  often  found  in  the  ear  in 
gouty  subjects.  These  may  cause  ulceration.  Again,  the  lobe  of  the  ear 
may  become  swollen,  red,  and  glistening  as  an  attack  of  gout  is  being 
developed. 

Among  insane  patients,  the  ear  frequently  becomes  deformed  from 
oethaimatoma. 


THE   FACE,    AS   A    WHOLE,    IN   DIAGNOSIS.  155 

Persistent  discharge  of  pus  from  the  ear  indicates  disease  within  the 
temporal  bone.  Fatal  brain  complications  may  arise  from  an  extension 
of  such,  ear  troubles  to  the  coverings  of  that  organ. 

The  Face  as  a  Whole. — Among  the  diseases  of  the  nervous  s^^stem, 
there  are  certain  types  of  physiognomy  which  are  so  characteristic  as  to 
be  of  the  most  positive  value  in  diagnosis. 

In  attacks  of  epilepsy  the  neck  at  first  becomes  tAvisted,  the  chin 
raised  and  brought  round  by  a  series  of  jerks  toward  one  shoulder.  The 
features  are  greatly  distorted.  The  brow  is  knit;  the  eyes  are  sometimes 
fixed  and  staring,  at  other  times  rolling  about  in  the  orbit,  and  again 
turned  up  beneath  the  eyelid,  so  that  the  cornea  is  covered,  and  only  the 
white  sclerotic  is  to  be  seen;  the  mouth  is  twisted  to  one  side  and  dis- 
torted; the  tongue  is  thrust  between  the  teeth,  and,  caught  by  the  violent 
closure  of  the  jaws,  is  bitten,  often  severely ;  and  the  foam  which  issues 
from  the  mouth  is  reddened  with  blood.  The  turgescenee  of  the  face 
indicates  obstruction  of  the  venous  circulation ;  the  cheeks  become  pur- 
plish and  livid,  and  the  veins  of  the  neck  are  visibly  distended. 

During  the  fit  of  exacerbation,  in  an  attack  of  tetanus  or  lockjaw,  the 
aspect  of  the  sufferer  is  sometimes  frightful.  The  forehead  is  corrugated 
and  the  brow  knit,  thus  expressing  the  most  severe  type  of  bodily  suf- 
fering; the  orbicularis  muscle  of  the  eye  is  rigid,  and  the  eye  itself 
staring  and  motionless;  the  nostril  is  widely  dilated,  indicating  the 
extreme  distress  of  l:)reathing;  the  corners  of  the  mouth  are  drawn 
back,  exposing  the  teeth,  which  are  firmly  clinched  together;  and  the 
features,  as  a  whole,  have  a  fixed  and  ghastly  grin — the  so-called  "  risus 
sardonicus."  During  such  paroxysms  as  in  those  of  epilepsy,  the 
tongue  is  liable  to  become  protruded  between  the  teeth  and  to  be 
severely  bitten. 

In  chorea  the  facial  muscles  participate  in  the  general  eccentricity 
of  movement.  Watson  thus  describes  the  peculiarities  of  this  strange 
affection:  "The  voluntar}^  muscles  are  moved  in  that  capricious  and 
fantastic  way  in  which  we  might  fancy  they  would  be  moved  if  some  in- 
visible mischievous  being,  some  Puck  or  Robin  Goodfellow,  were  behind 
the  patient  and  prompted  the  discordant  gestures.  With  all  this  the 
articulation  is  impeded ;  there  is  the  same  perverse  interference  with  the 
muscles  concerned  in  the  utterance  of  the  voice.  By  a  strong  figure  of 
speech  the  disorder  might  be  called  'insanity  of  the  muscles.' " 

In  catalejysy  the  patient  lies  often  with  eyes  open  and  staring,  yet 
without  expression  indicative  of  life ;  more  like  a  wax  figure  or  a  corpse 
than  like  a  living  subject.  The  features  may  be  made  to  assume  any  ex- 
pression, no  matter  how  absurd,  as  the  tissues  have  their  normal  pliability, 
and  they  will  remain  so  placed  until  again  mechanically  altered.  This 
same  peculiarity  is  also  present  in  the  muscles  of  the  extremities,  and 


156  LECTURES   OX   NERVOUS   DISEASES. 

forms  one  of  the  distinguishing  tests  of  the  disease.  The  mental  faculties 
are  in  abeyance,  and  all  ])ower  of  voluntary  motion  is  lost.  The  sensi- 
bility of  the  body  seems  also  to  be  lost. 

In  hj/stero-epilepsy  the  contortions  of  the  face  and  ])ody  are  often 
frightful.  In  rare  cases  consciousness  mny  l»e  retained  throughout  the 
attack. 

The  deformities  efface  and  intellect  which  seem  to  V)e  the  result  of 
residence  in  special  atmospheric  conditions,  or  of  certain  well-defined  lo- 
calities, are  illustrated  in  that  race  of  people  found  in  Yalais  and  the  ad- 
joining cantons  of  Switzerland,  called  "  cretins."  Manj-  of  these  wretches 
are  incapable,  according  to  Watson,  of  articulate  speech;  some  are  l)lind, 
some  are  deaf,  and  some  suffer  from  all  of  these  privaticms.  They  are 
mostly  dwarfish  in  stature,  with  large  heads;  wide,  vacant  features;  gog- 
gle eyes;  short,  crooked  limbs,  and  swollen  bellies.  The  worst  of  them 
are  insensible  to  the  decencies  of  nature,  and  in  no  class  of  mortals  is 
the  impress  of  humanity  so  pitiably  defaced.  The}-  are  usually  the  de- 
scendants of  parents  afHicted  with  goitre. 


(%. 


^ 
*<^. 


X 


Fig.  43. — The  Hand  in  Pkogkessive  Muscular  Atrophy. 

The  Hand. — Among  certain  forms  of  nervous  disease  characteristic 
deformities  of  the  hand  are  sometimes  encountered.  These  will  be  con- 
sidered separately.  Tremor  and  spasm  of  the  fingers  are  also  developed, 
in  some  cases,  and  require  a  hasty  description. 

The  deformities  of  the  hand  that  are  commonly  observed  include  (1) 
that  of  so-called  "progressive  muscular  atroph}';"  (2)  that  of  a  spinal 
disease  known  as  "amyotrophic  lateral  spinal  sclerosis;''  (3)  that  of  in- 
jury of  the  ulnar  nerve;  (4)  that  of  injury  of  the  musculo-spinal  nerve; 
(5)  that  of  injury  of  the  median  nerve  ;  (6)  that  of  paralysis  agitans  ;  and 
(7)  that  of  gout  and  rheumatism. 

The  tremors  of  the  hand  include  (1)  those  of  a  condition  called 
"athetosis;"  (2)  those  of  chorea  or  St.  Vitus'  dance;  (3)  those  of  paral- 
ysis agitans;  (4)  those  of  the  general  paralysis  of  the  insane;  and  (5) 
those  produced  by  circumscribed  lesions  of  tiie  nerve  centres. 


THE   HAND,    AS   AN    AID    IN   DIAGNOSIS. 


157 


In  }>rogressive  muscular  afrop/nj  the  ball  of  the  thumb  is  often  the 
starting-point  of  the  disease.  This  eminence  gradually  shrinks  and  dis- 
appears. It  should  be  remembered  that  the  disease  attects  symmetrical 
and  homologous  parts ;  hence  both  hands  are  liable  to  present  the  same 
deformity.  Gradually  the  muscles  between  the  bones  of  the  hand  shrink, 
so  that  the  bones  stand  out  unnaturally.  Fibrillary  twitchings  over  the 
affected  muscles  should  always  be  looked  for,  as  they  are  seldom  absent. 
The  temperature  is  lowered  over  the  atrophied  muscles. 


Fig.  44. — Ulnar  Paralysis.     (After  Bramwell. 


In  amyotrophic  lateral  spinal  sclerosis  the  hand,  when  affected,  is 
strongly  Hexed  upon  the  forearm,  the  fingers  are  shut  tightly  upon  the 
palm,  and  the  thumb  is  drawn  inward  toward  the  fingers.  Attempts  to 
straighten  the  fingers,  thumb,  or  hand,  will  be  strongly  resisted,  and 
cause  pain.  In  course  of  time  the  affected  muscles  become  markedly 
shrunken,  thus  adding  to  the  deformity  described.  Fibrillary  twitchings 
may  be  easily  excited  in  the  affected  muscles,  provided  they  do  not  spon- 
taneously exist. 

When  paralysis  of  the  ulnar  nerve  exists,  adduction  of  the  hand  is 
no  longer  performed  in  a  perfect  manner,  since  the  flexor  carpi  nlnaris 
can  no  longer  act  in  unison  with  the  extensor  carpi  ulnaris.     Flexion 


15S 


LECTURES    ON    NERVOUS   DISEASES. 


of  tile  liaiid  is  jXTtbrmed  inipcrfi'ctly,  and  b}^  moans  of  tlie  flexor  of 
the  ladial  side  of  the  forearm  only,  since  that  mnscle  is  supplied  by 
the  median  nerve.  The  ability  to  move  the  little  finger  is  almost  entirely 
abolished.  Complete  flexion  of  the  inner  three  fingers  is  rendered  diffi- 
cult and  sometimes  impossible.  The;  lingers  cannot  be  separated  from 
each  other,  or  compressed  into  a  close  lateral  juxtaposition,  owing  to 
paralysis  of  the  interossei  muscles;  and  flexion  of  the  first  phalanx  and 
extension  of  the  two  terminal  phalanges  of  all  the  fingers  are  rendered 
impossible,  for  the  same  reason. 

When  the  ulnar  nerve  is  paralyzed  above  the  wrist,  so  that  the  in- 
terossei and  lumbricales  are  alone  paralyzed,  the  hand  assumes  a  diag- 
nostic attitude,  the  so-called  "claw-hand."  in  which  the  extensor  com- 
munis digitorum  muscle  extends  the  first  phalanges  of  all  of  the  fingers. 


Fig.  45. — Median  Paralysis. 


while  the  other  two  rows  of  phalanges  are  flexed  by  the  common  flexor 
muscles  of  the  fingers  (the  interossei  and  lumbricales  being  no  longer 
able  to  flex  the  first  row  of  phalanges,  or  to  extend  the  two  other  rows). 
This  same  condition  of  the  hand  may,  however,  be  produced  by  a  con- 
dition of  progressive  muscular  atrophy  of  these  muscles. 

It  must  l)e  remembered  that  this  condition,  if  dependent  upon  ulnar 
paralysis  alone,  is  more  marked  in  the  two  inner  fingers  than  in  the  three 
outer,  since  the  lumbricales  are  supplied  in  part  by  the  median  nerve. 
This  clinical  fact  seems  to  stamp  the  action  of  the  lumbricales  as  similar 
to  that  of  the  interossei.  Finally,  the  efiects  of  idnnr  paralysis  may  be 
manifested  in  the  movements  of  the  thumb,  since  it  supplies  two  muscles 
which  control  it.  This  will  be  most  apparent  when  the  patient  is  re- 
quested to  press  the  thumb  forcibly  against  the  metacarpal  bone  of  the 
index  finger,  or  to  adduct  the  thumb. 


THE   HAND,    AS   AN    AID    IN   DIAGNOSIS.  159 

Wlien  paralyi^s  of  the  median  nei've  exists,  the  second  j)haUin<>es  of 
all  the  fingers,  and  the  third  phalanges  of  the  index  and  middle  fingers 
cannot  be  flexed,  and  the  thumb  cannot  be  flexed  or  brought  into  contact 
with  the  little  finger.  On  the  other  hand,  flexion  of  the  first  phalanx, 
with  extension  of  the  other  two,  can  be  performed  in  all  the  fingers  by 
the  aid  of  the  interossei,  which  are  supplied  by  the  ulnar  nerve.  The 
position  of  the  thumb  is  peculiar;  it  is  extended  and  adducted  and  thus 
closely  applied  to  the  index  finger,  as  in  the  hand  of  the  ape.  The  hand, 
when  flexion  at  the  wrist  is  attempted,  is  strongly-  adducted  by  the  action 
of  the  flexor  carpi  ulnaris,  because  the  antagonistic  muscle  of  the  radial 
side  is  paralyzed.  The  act  of  phonation  of  the  hand  is  seriously  im- 
paired. The  inner  three  fingers  can  be  brought  into  a  partially  flexed 
condition,  since  the  flexor  profundus  digitorum  muscle  is  partly  supplied 
])V  the  ulnar  nerve.     These  combined  eff'ects  give  to  the  hand  and  fingers, 


Fig.  4P. — Musculo-spiual  Paralysis. 

and  especially  to  the  thumb,  a  position  no  peculiar  that  paralysis  of  the 
median  could  hardly  be  mistaken  by  an  anatomist  for  any  other  deformity, 
when  the  paralyzed  muscles  begin  to  show  the  results  of  atrophy,  the 
deformity  in  the  forearm  and  in  the  ball  of  the  thumb  Avill  further  assist 
in  the  diagnosis  of  this  atfection. 

The  musculo-spiral  nerve  is  more  frequently  affected  with  paralysis 
than  any  of  the  nerves  of  the  upper  extremity.  It  is  particularly  liable 
to  both  peripheral  and  central  causes  of  paralj'^is ;  thus  in  the  cerebral 
hemiplegia,  the  muscles  supplied  by  this  nerve  ai*e,  perhaps,  more  com- 
monly affected  than  those  supplied  by  any  other  nerve,  while  paralj^sis 
of  these  muscles  is  common  as  the  result  of  chilling  of  the  upper  ex- 
tremity, traumatism,  and  lead-poisoning. 

The  anatomical  situation  of  the  muscnlo-spiral  nerve  and  the  pecu- 
liarity of  its  course  around  the  humerus,  probably  explain  the  frequent 
occurrence  of  paralysis,  since  it  may  be  easily  compressed  by  sleeping 
upon  the  arm.     It  is  common  to  meet  with  this  type  of  paralysis  in 


160 


LECTURES   ON    NERVOUS   DISEASES. 


putii'iits  who  have  used  their  anus  as  a  pillow,  or  iu  druukards  who  luiw 
slept  iu  some  constrained  position  upon  benches,  steps,  etc.  Persons 
who  have  fallen  exhausted  and  have  rested  upon  the  arm,  and  soldiers 
who  have  slept  upon  the  damp  ground,  often  arise  with  this  form  of 
paralysis.  It  is  stated  bv  Brenner  that  the  coachmen  of  Russia,  who  are 
in  the  habit  of  sleeping  upon  the  box  with  the  reins  wound  around  the 
ujjper  arm,  are  victims  to  this  condition;  and  Bachon  reports  the  same 
result  as  common  among  the  water-carriers  of  Rennes,  since  they  pass 
their  arm  through  the  handle  of  the  heavy  water-pails  to  more  securely- 
compress  them  against  the  chest.  The  lia]>it  of  the  Russians  of  tight!}' 
bandaging  the  arms  of  infants  to  the  body,  and  allowing  them  to  sleep 
upon  one  side  for  long  intervals,  seems  to  promote  the  frequent  occur- 
rence of  this  trouble. 

Among  the  other  forms  of  traumatism  wdiicli  conduce  toward  this 
form  of  paralysis  may  be  mentioned  the  use  of  poorly-padded  crutches, 
the  kicks  of  animals,  cuts,  stab-wounds,  fractures  of  the  humerus,  dislo- 
cation of  the  humerus  at  the  shoulder-joint,  and  the  development  of  an 
excessive  amount  of  callus  after  a  fracture. 

Rheumatic  affections  and  a  neuritis  of  the  musculo-spiral  nerve  are 
reported  as  causes  by  Bernhardt  and  others;  and  cases  of  hj^sterical 
origin  have  been  rarely  but  positively  authenticated. 

Finally,  lead-poisoning  must  be  mentioned  as  one  of  the  most  com- 
mon causes  of  paralysis  of  the  muscles  supplied  b}'  the  musculo-spiral 
nerve.  The  existence  of  this  form  of  poisoning  will  have  generally  been 
indicated,  previous  to  the  appearance  of  paralysis,  by  colic,  jaundice,  and 
arthralgia,  as  the  muscles  are  seldom  att'ected  until  the  latter  stages.  The 
extensor  communis  digitorum  muscle  is  usually  affected  first,  and  the 
paralysis  gradually  extends  to  the  other  muscles  supplied  by  the  musculo- 
spiral  nerve.  The  muscles  of  the  arm  are  much  less  frequently  affected 
than  those  of  the  hand  and  forearm;  but  in  severe  cases  the  muscles  of 
the  upper  arm  are  involved,  and  the  thumb  and  the  index-finger  cannot 
be  extended  or  abducted ;  the  patient  cannot  supinate  the  hand  when  the 
forearm  is  extended  (this  position  being  assumed  in  order  to  exclude  the 
action  of  the  biceps  muscle),  nor  can  the  forearm  be  half  bent  and  the 
hand  half  supinated  by  the  supinator  longus  muscle;  and,  finally,  when 
the  patient  is  instructed  to  flex  the  forearm,  when  placed  in  a  position  of 
half  flexion  and  semi-pronation,  the  supinator  longus  muscle  lies  flaccid, 
and  does  not  become  tense  and  hard  as  in  health.  The  loss  of  power  in 
the  triceps  muscle  renders  it  impossible  for  the  patient  to  extend  the  fore- 
arm upon  the  arm  when  the  arm  is  first  raised  above  the  head  ;  nor  can 
the  forearm  be  extended  with  the  same  degree  of  force  as  the  health}- 
side  in  any  position  of  the  arm.  When  the  hand  is  laid  upon  the  table, 
the  patient  is  unable  to  raise  the  hand  from  contact  with  it,  but  the  lateral 
movements  of  the  fingers  can  be  performed  as  in  health. 


THE   HAND,    A«   AN    AID   IN   DIAGNOSIS, 


161 


In  (jout  the  joints  become  enlarged  and  serionsl}^  crippled  by  deposits 
of  urate  of  soda,  that  cause  prominent  nodules  upon  the  fingers.  These 
often  ulcerate.  The  index  and  middle  fingers  are  the  ones  most  frequently 
deformed.  Occasionally  one  finger  will  be  drawn  toward  the  palm  by 
gouty  inflammation  in  the  sheath  of  its  flexor  tendon.  If  this  dtforniity 
be  found,  always  examine  the  other  hand  to  see  if  a  similar  deformity  is 
not  more  or  less  developed  on  both  sides.  If  so,  it  is  almost  a  positive 
sign  of  gout. 

The  diseased  condition,  called  '■'athetosis'^  because  the  fingers  do  not 
maintain  a  fixed  position,  is  characterized  by  a  continual  motion  of  the 
fingers  and  toes,  and  an  inability  on  the  part  of  the  patient  to  retain  them 
in  any  fixed  attitude.  These  patients  cannot  keep  the  hand  closed  or 
open,  even  for  a  short  period,  although  the  fingers  are  to  some  extent 


Fig.  47. — Athetosis.     (After  Hammond.) 


under  the  control  of  the  will.  The  toes  are  not  commonly  afiected  to 
the  same  degree  as  the  fingers.  The  movements  of  the  fingers  and  toes 
are  perpetual,  not  being  entirely  arrested  during  the  hours  of  broken  sleep. 

The  tremor  of  paralysis  agitans,  or  ''shaking  palsy,"  is  markedly 
aggravated  by  voluntary  muscular  effort  or  mental  excitement.  Except 
in  ver}'  aggravated  cases,  it  ceases  during  sleep.  During  the  daytime  it 
is  more  or  less  persistent  and  uncontrollable. 

In  imbeciles,  rhythmic  movements  of  the  hands  are  commonly  met 
witli.  They  are  in  marked  contrast  to  the  irregular  and  spasmodic  moA^e- 
ments  observed  in  St.  Vitus'  dance. 

During  an  attack  of  acute  hydrocephalus,  or  "water  on  the  brain," 
the  thumbs  are  usually  flexed  upon  the  palm. 

Langdon  Down  has  described  the  so-called  ^•woolly  hand"  of  the 
idiot;  the  skin  being  too  abundant  for  its  size,  and  forming  wrinkles 
upon  it. 

11 


162  LECTURES   ON    NEKVOUS    DISEASES. 

Ill  all  diseases  wiiicli  fut  off  thf  nerve  Jibre.'<  /'ruin  their  centres  of 
nutrition,  or  "trophic  centres"  as  tliey  are  called,  or  after  injuries  to 
the  nerves,  the  skin  of  the  hand,  as  Avell  as  of  other  parts,  may  become 
smooth,  shining,  and  atfected  with  eruptions  or  ulceration.  The  nails 
and  hair  may  also  give  evidences  of  imperfect  nutrition. 

THE   (tAIT   AXD    attitude   OF   THE   PATIENT   AS   A   FACTOR    IN 

DIAGNOSIS. 

Among  the  symptoms  wiiich  are  brought  to  the  notice  of  the  neu- 
rologist by  his  perceptive  faculties,  none  are  more  positivel}'  diagnostic 
than  the  abnormalities  of  gait  and  attitude  which  are  frequentl}-  encoun- 
tered. It  will  simplify  description  to  consider  first  the  more  common 
abnormalities  of  gait,  and  subsequently  the  characteristic  attitudes  pro- 
duced by  nervous  aft'ections. 

Gait  of  Hemiplegia. — This  condition  (in  which  one  lateral  half  of 
the  body  is  paralyzed)  is  evidenced  by  a  characteristic  gait,  if  the  paral- 
ysis is  not  so  profound  as  to  prevent  all  attempts  at  walking.  The  arm 
hangs  at  lirst  limp,  and,  in  some  cases  (later  on;,  more  or  less  rigid  on 
the  atfected  side.  The  shoulder  droops  upon  the  paralyzed  side.  At 
each  step  the  paralyzed  half  of  the  body  is  lifted;  in  order,  as  it  were,  to 
swing  the  weak  leg  forward.  This  movement  causes  the  shoulder  to  tilt 
toward  the  healthy  side,  and  the  pelvis  to  be  raised;  while  at  the  same 
time,  the  leg  is  not  bent  at  the  knee  as  in  health.  The  shoe  of  the  para- 
lyzed leg  trails  along  the  ground  as  it  is  swung  forward,  and  the  toe  and 
outer  part  of  the  sole  of  the  shoe  becomes  worn  off  rapidly,  a  clinical 
point  not  to  be  overlooked.  The  back  is  not  arched,  as  in  the  spastic 
form  of  paralysis,  and  the  feet  do  not  tend  to  cross  the  median  line.  The 
term  "sickle-walk"  is  applied  by  French  authors  to  this  variety  of  gait, 
on  account  of  the  swinging,  semi-circular  movement  of  the  paralyzed 
foot.  The  patient  usually  carries  a  cane  on  the  healthy  side,  to  aid  him 
in  walking. 

Gait  of  Paraplegia. — Both  legs  (or,  to  be  more  accurate,  the  lower 
half  of  the  body)  ma}'  be  more  or  less  paralyzed,  and  yet  the  patient  can 
walk.  How  different  is  the  gait,  however,  from  that  of  health!  These 
patients  shuffle  along  without  raising  either  foot  from  the  ground  to  any 
appreciable  extent,  so  that  they  cannot  be  said  to  step.  The  progression 
is  extremely  slow,  because  the  length  of  the  step  (if  it  may  be  so  called) 
is  very  short.  The  heel  of  one  foot  rarely  passes  the  limit  of  the  toe 
of  its  fellow,  if  the  paraplegia  is  well  developed.  This  gait  differs  from 
that  of  spastic  paraplegia  chiefly  in  the  absence  of  the  stitthess  of  the  legs 
and  the  interlocking  of  the  knees,  which  are  both  present  in  the  other. 
The  so-called  "hopping  gait  "  is  not  developed  as  in  the  other  form.  The 
back  is  not  arched. 


GAIT   AND   ATTITUDE   AS    A    FACTOR   IN    DIAGNOSIS. 


163 


Gait  of  Spastic  or  Tetanoid  Paraplegia. — In  the  eiirly  stages  of 
this  disease  a  combination  of  paresis,  muscular  rigidity,  and  occasional 
tremor  exists.  Tlie  feet  are  turned  inward  and  appear  to  be  tirmly  glue: I 
to  tlie  ground  during  attempts  at  walking,  and  are  scraped  along  with  a 
characteristic  noise.  Thej'^  often  cross  each  other  in  walking,  and  the 
knees  are  liable  to  become  locked  together.  These  subjects  are  particu- 
larly prone  to  fall  in  spite  of  the  use  of  canes  or  crutches,  because  the 


Fig.  48  —Paralysis  Agitan;?,  or  Shaking  Palsy.     (Charcot.) 

slightest  irregularity-  in  the  pavement  may  catch  their  shoe  as  it  is  slid 
along  the  ground.  These  patients  sometimes  exhibit  a  "hoi)ping  gait" 
when  the  muscles  of  the  calf  become  affected  with  spasm.  The  back  is 
strongly  arched  and  the  chest  is  thrown  forward.  The  patient  throws 
his  weight  first  on  one  cane  and  then  on  the  other,  in  order  to  lift  his 
bod}"  so  as  to  move  his  feet. 

Gait  of  Paralysis  Agitans. — The  tottering  and  trembling  gait  of 
these  subjects,  with  a  tendency  to  trot  rather  than  walk  when  under  full 


164 


LECTURES   ON    NEKVOUS   DISEASES. 


ln'iuhvav,  is  clianicteristic.  The  sliakiiig  hands  are  nsiiall}'  held  out  in 
front  of  the  body,  which  is  bent  forward  as  they  run.  These  subjects  are 
tienerally  well  advanced  in  age.  The  head  is  projected  forward  and  held 
stiffly  when  walking,  and  the  "vertebra  prominens"  stands  out  in  bold 
relief.     Fig.  48  illustrates  this  point  very  well. 

Gait  OK  Psel  do-Hypkrtrophic  Paralysis. — These  subjects  are  always 
children.  Tiu-  innnense  calf  muscles  are  strangely  in  contrast  with  their 
paralytic  synii)tonis.  When  they  attempt  to  walk  the  gait  has  been  aptly 
compared  to  the  "waddling  of  a  duck."     The  back  is  excessively  curved 


T"iG.  40. — Attitude  of  Pseudo-Hypertrophic  Paralysis.     (Duchenne.) 

in  the  erect  posture,  so  that  a  line  dropped  from  the  shoulders  falls  behind 
the  hips.  The  peculiarities  of  attitude  of  these  patients  will  be  consid- 
ered later. 

Gait  of  Locomotor  Ataxia  or  Tabks  Dorsalis. — These  subjects 
straddle  as  they  walk.  The  legs  are  flung  about  in  an  uncertain  and  ap- 
parently aimless  manner,  although  the  steps  are  taken  with  marked  de- 
liberation. The  feet  are  brought  down  with  the  heel  projecting,  thus 
creating  a  "stamping"  and  "flopping"  gait.  These  patients  keep  their 
ej-es  steadily  upon  the  ground  w-hen  walking.    The}'  have  no  motor  paral- 


ATTITUDES   ASSUMED   IN    NERVOUS   DISEASES.  165 

ysis,  as  is  shown  by  testing  the  various  muscles  separately;  the  abnormal 
gait  being  due  purely  to  an  inability  to  properly  coordinate  the  various 
groups  of  muscles.  These  patients  are  frequently  subjected  to  severe 
and  unexpected  falls  after  marked  incoordination  of  movement  is  de- 
veloped, and  generally  resort  to  the  use  of  strong  canes  when  walking. 

Gait  of  Hysterical  Palsy. — The  feet  are  dragged  or  shuffled  along 
ill  the  paraplegia  of  h^'steria,  but  one  foot  is  usually  more  affected  than 
its  fellow.  There  is  no  -'sickle-movement"  of  the  leg,  as  in  hemiplegic 
subjects.  These  subjects  use  a  cane  or  crutch,  or  cling  to  articles  of  fur- 
niture as  they  sluggishly  move  about  a  room.  It  is  liable  to  pass  away 
suddenly  and  is  usually  developed  as  suddenly-. 

Gait  of  Progressive  Muscular  Atrophy. — When  the  thigh  and 
calf  muscles  are  affected,  or  those  of  the  back  or  abdomen,  the  gait  is 
seriously  altered.  As  a  rule,  these  subjects  walk  as  a  sailor  does  upon 
land,  only  the  "roll"  is  exaggerated,  and  the  trunk  is  peculiarly  poised 
upon  the  legs.  The  gait  is,  however,  modified  by  the  seat  and  extent  of 
the  muscular  degeneration,  as  it  is  produced  in  each  case  by  the  inability 
of  a  certain  set  of  muscles  to  perform  their  normal  functions. 

Gait  of  Cerebellar  Disease. — Like  all  ataxic  subjects,  these  pa- 
tients stand  with  their  feet  wide  apart,  to  increase  their  base  of  support. 
When  walking  they  give  evidence  of  imperfect  coordination  of  the  mus- 
cles of  the  legs.  Sometimes  the^^  stagger  and  reel  like  an  intoxicated 
person.  If  the  feet  are  exposed  the  toes  will  be  seen  to  be  in  constant 
motion  when  an  effort  to  stand  on  one  spot  is  made,  as  if  they  were  en- 
deavoring to  bury  themselves  in  the  carpet. 

Gait  of  Reflex  Paralysis. — This  is  generally  of  the  "hemiplegic" 
variety.  One  leg  is  dragged  along  behind  the  other,  in  the  large  majority 
of  cases. 

Gait  of  Cerebro-Spinal  Sclerosis. — In  this  disease  we  meet  a  very 
characteristic  gait.  Slight  jerking  movements  of  the  head  and  neck  can 
be  perceived  in  the  early  stages.  Later  in  the  disease  the  symptoms  of 
marked  incoordination  of  the  muscles  are  apparent.  The  gait  is  then 
extremely  unsteady  and  irregular,  but  totally  unlike  that  of  locomotor 
ataxia,  in  that  the  muscles  of  the  trunk  as  well  as  those  of  the  legs  are 
affected.  These  patients  do  not  walk  deliberately  and  in  a  straight  line, 
but  shoot  suddenly  forward  or  to  one  side,  and  are  very  apt  to  knock 
against  articles  of  furniture  in  moving  about  a  room  and  to  fall  violently. 

THE   ATTITUDES   ASSUMED    IN   THE  MORE   SEVERE  FORMS  OF 
NERVOUS   DISEASES. 

Nervous  diseases  tend  in  some  instances  to  produce  abnormalities 
of  attitude.  The  limits  of  this  chapter  will  preclude  more  than  a  cur- 
sory view  of  this  field.  A  volume  would  be  required  to  properly-  exhaust 
the  headings  already  touched  upon. 


166  LECTUKES   ON,  NERVOUS   DISEASES. 

Anions'-  the  more  coiuinou  causes  of  abnormalities  ol  attitiuie  due  to 
nervous  lesions  may  be  mentioned  epilepsy,  tetanus,  hydropbol)ia.  spinal 
meningitis,  hysteria,  catalepsy,  hydrocephalus,  chorea,  athetosis,  arthro- 
pathy, the  many  forms  of  cerebral  and  spinal  paralyses,  the  different 
types  of  tremor  and  muscular  atrophy,  contracture,  or  reflex  spasm. 

Of  the  characteristic  attitudes  some  are  observed  only  in  the  erect 
posture  of  the  patient,  and  others  when  the  patient  moves  about.  Some 
are  recognized  when  the  patient  is  sitting,  while  again  others  are  present 
in  patients  con  lined  to  bed.  Attempts  at  movement  of  any  kind  some- 
times increases  the  deformit}',  while  again  walking  may  graduall}'  limber 
up  other  patients  and  render  the  defects  of  movement  less  apparent. 

In  connection  with  the  description  of  facial  evidences  of  nervous 
disease,  the  characteristic  facial  attitudes  of  Bell's  palsy,  Duclienne's  dis- 
ease, paresis  of  the  muscles  of  the  eye,  parah'sis  of  the  third  nerve,  the 
convulsions  of  epileps}-  and  tetanus,  the  condition  of  cataleps}',  and  the 
facial  spasm  of  St.  Vitus'  dance  have  been  alluded  to  and  in  part 
described. 

When  the  hand  Avas  considered,  the  attitudes  of  progressive  muscular 
atroph}',  paralysis  agitans,  and  the  results  of  paralysis  of  the  median, 
ulnar,  and  musculo-spinal  nerves  were  described  separately.  The  de- 
formities of  the  hand  in  gout,  and  the  attitude  of  the  thumb  and  fingers 
in  h3drocephalus,  athetosis,  and  imbecilit}^,  were  also  mentioned.  It  is 
not  necessary,  therefore,  to  again  describe  them. 

It  remains  for  me  to  touch  upon  some  of  the  more  important  atti- 
tudes which  have  as  yet  been  omitted. 

In  acute  hy proeephalus  the  tuberculous  deposit  at  the  base  of  the 
brain  creates  a  characteristic  attitude  when  the  condition  is  well  de- 
veloped. These  children  bore  their  head  into  the  pillow  and  roll  it  from 
side  to  side.  The  thumbs  are  flexed  upon  the  palms  during  sleep,  even 
before  the  severity  of  the  attack  is  reached.  The  pu})ils  are  at  first  con- 
tracted, but  they  become  dilated  when  coma  develops  from  the  pressure 
of  the  deposit  of  tubercle  upon  the  brain.  The  abdomen  is  markedly 
retracted. 

Linked  with  cerebrospinal  meningitis  we  notice  the  rigid  contrac- 
tion of  the  muscles  of  the  trunk,  resulting  in  a  curvature  of  the  back. 
The  head  is  also  thrown  backward  and  the  muscles  of  the  neck  are  more 
or  less  rigid.     Fever  and  an  eruption  are  also  present. 

Sooner  or  later  after  a  ^' stroke''^  of  paralysis,  a  state  of  rigidity  and 
contracture  of  the  paralyzed  muscles  often  develops.  It  causes,  as  a  rule, 
a  state  of  permanent  flexion  in  the  upper  limbs  and  that  of  extension  in 
the  lower.  This  post-paralytic  contracture,  if  developed  late,  is  thought 
by  some  authors  to  indicate  a  descending  degeneration  (?)  of  those  motor 
fibres  of  the  spinal   cord  that  haA'e  been  cut  oft"  from  their  so-called 


ATTITUDES   ASSUMED   IN   NERVOUS   DISEASES. 


167 


''trophic  centre''  by  the  exciting  lesion.  It  is  always  associated  with  a 
marked  increase  of  the  spinal  reflexes,  a  point  of  great  clinical  import- 
ance. This  condition  is  known  as  "tetanoid"  or  "spastic"  paralysis. 
The  peculiar  gait  of  these  subjects  has  been  previously  discussed. 

In  pseudo-Jiypertrophic  2J0,ralysis  the  child  first  gives  evidence  of  the 
commencement  of  the  disease  by  a  weakness  of  the  legs  and  a  clumsiness 
in  walking,  which  is  exhibited  by  frequent  stumbling  and  falls.  Gradually 
the  patient  assumes  a  characteristic  attitude  and  gait. 

The  attitude  is  ver}'  peculiar.  In  the  standing  posture  the  back  is 
thrown  beyond  the  proper  position,  so  that  a  vertical  line  dropped  from 
the  shoulders  frequently  falls  behind  the  sacrum  ;  tliis  antero-posterior 


Figs.  50,  61,  52,  53. — Attitudes  Assumed  in  Pseudo-Hvpertrophic  Par.\lysis 
During  Attempts  to  Rise.     (Gowers.) 


curvature  entirely  disappears,  however,  when  the  patient  is  in  the  sitting 
posture.  The  feet  are  placed  wide  apart  so  as  to  increase  the  base  of 
sui)port.  The  heels  are  usually  drawn  upward  by  a  contraction  of  the 
tendo-Achillis.  In  the  effort  to  preserve  the  balance  the  arms  are  held  at 
the  side  with  tlie  liauds  extended,  and  the  slightest  touch  may  cause  the 
patient  to  fall.  Another  remarkable  feature  of  the  disease  is  the  ditli- 
culty  whicli  is  experienced  in  rising  from  the  recumbent,  or  even  the 
sitting  posture.  The  sufferer  uses  surrounding  ol)jects  as  a  means  of 
rising,  drawing  the  body  upward  by  the  hands.  When  unable  to  reach 
such  assistance,  the  steps  which  are  taken  to  rise  are  thus  described  by 
Gowers:  "If  laid,  for  example,  on  iiis  l)aek  upon  the  floor  and  told  to 


168 


LEfTrPiES   0\   NERVOUS   DISEASES. 


rise,  he  would  livsl  with  i^i'^'^it  (lilhculty  turn  on  liis  fac(';  he  would  next 
get  on  his  knees,  his  head  being  almost  between  his  thighs;  from  this 
position  he  would  gradually  extend  himself,  so  that  he  stands  ni)on  liis 
feet  and  hands  with  all  his  limbs  extended  ;  finally  lie  would  extend  the 
hip-joint  by  grasping  the  thigh  with  the  hand  and  pushing  up  the  body,  as 
it  were,  by  the  arm."  This  movement  of  '-climbing  Tip  the  thighs,"  as  it 
has  ])een  termed,  is  an  indication  of  weakness  in  tiie  muscles  which 
straighten  the  knee,  and  also  those  which  extend  the  trunk  u])()n  the 
thigh — the  extensors  of  the  hip-joint. 


Fig.  54. — Attitude  Created  by  Atrophy  of  the  Back  Muscles.     (Bramwell  ) 

The  gait  of  these  patients  is  associated  with  an  oscillation  of  the 
body  from  side  to  side,  or  a  waddling  movement.  The  advance  made  at 
each  step  is  ver}-  small,  and  a  difficulty  seems  to  be  experienced  in  flexing 
the  thigh  upon  the  abdomen. 

The  muscles  of  the  calf  exhibit  early  a  firmness  and  increase  in  size 
which  is  not  proportionate  to  their  motor  force — as  that  is  far  below 
normal.  Soon  they  become  excessively  developed,  as  do  also  those  of 
the  buttock;  while  the  other  muscles  of  the  leg  commonly  grow  smaller 
from  atrophic  changes. 


ATTITUDES   ASSUMED   IN    NERVOUS   DISEASES. 


IG9 


The  Intissiinus  dorsi  and  tlu'  lower  part  of  tlic  pectoralis  major 
muscles  exhibit  marked  wasting  in  a  very  large  percentage  of  cases.  In 
some  instances  all  the  striated  muscular  fibres  of  the  body,  including 
even  the  heart,  may  become  affected. 

In  apinal  meningitis  of  the  acute  form  the  patient  lies  with  the  legs 
and  thighs  flexed,  and  show^s  evidences  of  great  suffering  in  the  coun- 
tenance. The  muscles  of  the  neck  are  attacked  by  spasms  which  draw 
the  head  backward.  The  patient  dreads  all  movements,  because  they 
increase  ])oth  the  pain  and  the  spasms  of  the  muscles. 


Fig.  5.'). — Attitude  Created  by  Atrophy  of  the  Abdominal  Muscles.     (Bramwell.) 


Children  affected  with  acute  poliomyelitis  are  often  delirious  and 
have  febrile  symptoms.  The  paralyzed  limbs  lie  motionless  and  the 
muscles  are  flaccid.  Tremors  and  twitchings  in  the  facial  muscles  and 
the  tendons  of  the  wrist  are  often  observed,  but  they  are  the  result  of  a 
rapid  elevation  of  the  tem])erature  rather  than  a  symptom  of  this  special 
disease. 

In  progressive  mvscular  atrophy  the  "bird-claw^"  appearance  of  the 
fingers  attracts  attention  at  once  (Fig.  43).  When  the  muscles  of  the 
arm  and  forearm  are  badly  wasted  the  limb  hangs  at  the  side  in  a  help- 


170  LECTURES   ON    XERVOFS   DISEASES. 

less  Ava}',  ''as  if  it  were  tied  to  the  liody  l)y  strings."  If  the  muscles  of 
the  lumbar  region  be  attacked  the  belly  becomes  slightly  prominent  and 
tense,  and  the  back  is  strongly  arched  in  order  to  balance  the  trunk 
(Fig.  54).  A  line  di'opped  from  the  shoulders  fulls  behind  the  hips  as 
tiie  patient  stands  erect.  If  the  abdominal  muscles  are  atrophied  the 
belly  falls  forward  to  a  marked  extent,  and  the  back  is  arched  in  such 
a  manner  by  the  healthy  lumbar  muscles  that  a  vertical  line  from  the 
shoulders  passes  through  the  sacral  region  (Fig.  55).  The  muscles  of 
the  lower  limbs  are  seldom  so  severely  wasted  as  to  prevent  the  patient 
walking. 

In  hysterical  paralysis  the  patient  (usually  a  young  woman)  is  often 
confined  to  the  bed.  Todd  has  described  the  facial  appearance  of  this 
class  of  patients  as  characterized  by  a  "remarkable  depth  and  prominent 
fullness  with  more  or  less  thickening  of  the  upper  lip,  and  by  a  peculiar 
drooping  of  the  upper  eyelid.'*  Sometimes  the  muscles  of  the  limbs  are 
flaccid,  while  in  others  the  legs  are  stiffly  extended  and  the  feet  arc 
turned  inward.  The  nutrition  of  the  muscles  is  generally  good,  and 
marked  atrophy  is  seldom  present. 

In  cerebrospinal  sclerosis  the  face  first  attracts  attention  by  a  stupid 
and  vacant  expression,  the  half-open  mouth,  an  oscillation  of  the  eye- 
balls (nystagmus)  in  some  instances,  and  a  contracted  state  of  the  pupils 
in  many  cases.  The  speech  is  liable  to  be  of  a  "drawling"  character, 
and  the  tone  of  the  voice  monotonous.  The  head  is  often  turned  slightly 
to  one  side  during  attempts  at  walking,  or  perhaps  is  drawn  a  little  back- 
ward— a  point  which  is  explained  by  Bramwell  as  an  effort  on  the  part 
of  the  patient  to  prevent  unsteadiness  of  the  head  by  an  artificial  stiff- 
ness of  the  neck.     The  gait  has  alreach*  been  described. 

SYMPTOMS    OF   NERVOUS   DISEASES   REVEALED   BY   THE 
EMPLOYMENT    OF   VARIOUS   TESTS. 

We  are  prepared  b}'  what  has  lieen  said  in  the  preceding  pages  of 
this  volume,  to  consider  intelligently  the  various  tests  which  are  em- 
ployed (exclusive  of  the  tests  of  vision  which  have  been  already  dis- 
cussed) as  aids  in  the  diagnosis  of  certain  forms  of  nervous  diseases. 
The  following  table  may  aid  the  reader  in  his  study  of  the  closing  pages 
of  this  section : — 

A  TABLE  OF  THE  MORE  IMPORTANT  TESTS  OF  THE  NERVE 
OR  NERVE  CENTRES. 

Tests  employed  to  determine  the  reflex  excitability  of  the  spinal  cord: — 

1.  The  "superficial"  or  skin  reflexes. 

2.  The  "deep"  or  tendon  reflexes. 

•"..       The  "ORCAXIC"    reflexes. 


SYMPTOMS   EEVEALEI)    ]5Y    VAKIOUS    TESTS.  171 

Tests  of  MoTOii  I'AKAiiYsis  an;  (;nijiloy(;<l  for  the  fblluwuig  purposes: — 

1.  To  deteriniuc  its  exact  limits. 

2.  To  determine  its  distribution. 

3.  To  determine  the  trophic  condition  of  the  affected  muscles. 

■1.     To  determine  the  power  of  co-ordination  of  muscular  movement. 
5.     To  determine  the  so-called  "muscular  sense." 
H.     To  determine  the  irritability  of  the  muscles. 

Tests  to  determine  tlic  "irritability"  of  the  muscles; — 

A.  Mechanical  tests— 

1.  For  "  diminished  muscular  iciision." 

2.  l''or  "  increased  muscular  tension." 
'i.     For  fibrillary  twitchimjs. 

4.  For  tremors. 

5.  For  contracture  of  muscles. 

B.  Electric  tests — 

1.  By  thti  fai^adic  current. 

2.  By  the  galvanic  current. 

Tests  for  the  sensory  nerves  enable  us  Id  decide  respecting  the  foHowiug  conditions: — 
A.     Abmn-nialities  of  tactile  sensibility — 

1.  Ancesthesia. 

2.  Hypercesthesia. 

.'!.     Delayed  sensation. 
11.     Abnormalities  of  sensibility  to  temperature. 

C.  Abnormalities  of  sensibility  to  pain, 

D.  Abnormal  condition  of  the  organs  of  the  special  senses. 

THE    SPINAL   REFLEXES. 

"Superficial"  or  "Skin  Reflexes." — These  are  performed  by  dif- 
ferent segments  of  the  cord. 

Stimulation  of  the  skin  of  the  sole  of  the  foot  by  a  scratch,  prick,  or 
touch  with  the  nail,*  for  example,  induces  a  contraction  of  the  foot 
muscles  {plantar  reflex)  through  the  lower  part  of  the  lumbar  enlarge- 
ment of  the  cord. 

The  skin  of  the  buttock  calls  into  action  the  glutei  muscles  {gluteal 
reflex)  through  a  segment  which  corresponds  to  the  escape  of  the  fourth 
or  fifth  lumljar  nerve. 

The  skin  upon  the  inner  aspect  of  the  thigh  causes  the  cremaster 
muscle  to  draw  the  corresponding  testicle  toward  the  external  al)dominal 
ring  {cremaster  reflex)^  by  influencing  the  cord  at  the  level  of  the  first 
or  second  lumbar  nerves. 

The  skin  upon  the  side  of  the  abdomen  creates  refiex  movements  of 
the  abdominal  muscles  {abdominal  rejlex)  by  affecting  a  segment  of  the 
cord  situated  between  the  levels  of  the  eighth  and  twelfth  dorsal  nerves. 

*  A  sharp-pointed  instrument  is  best  adapted  for  the  excitation  of  tlie  skin  reflexes. 


172  LECTURES   ON    NERVOUS    DISEASES. 

The  skin  upon  the  side  of  the  chest  creates  a  reflex  response  in  the 
region  of  tlie  epii;:istrium  (cpif/dxtric  rejlex),  which  depends  ui)on  a  spinal 
segment  extending  IVom  the  fourth  to  the  seventh  dorsal  nerves. 

Finally,  the  skin  between  the  shoulder  blades  causes  the  posterior 
axillary  fold  or  the  teres  major  muscle  to  contract  (scapular  reflex), 
by  influencing  the  spinal  segment  between  the  levels  of  the  fifth  cervical 
and  third  dorsal  nerves. 

By  means  of  these  rejlexes  we  are  thus  enabled  to  test  the  various 
spinal  segments  from  the  neck  to  the  terminal  extremit}^  of  the  cord. 
Should  any  be  found  to  be  absent  it  should  be  remembered  :  (1)  that  the 
reflex  excitability  of  the  cord  varies  with  individuals,  and  is  always 
greater  in  youth  than  old  age;  (2)  that  the  plantar,  cremasteric,  ab- 
dominal and  epigastric  reflexes  are  variable  in  health  but  are  more  con- 
stant than  the  scapular;  (3)  that  cerebral  lesions  may  impair  them  on 
the  side  of  the  hemiplegia,  for  reasons  not  as  yet  well  understood  ;*  and 
(4)  that  systematic  lesions  of  Burdach's  or  Goll's  columns  (see  Fig.  32) 
tend  to  diminish  or  abolish  them. 

Deep  or  "Tendon  Reflexes." — These  are  also  of  great  value  as  a 
means  of  determining  the  condition  of  excitability  of  different  segments 
of  the  cord.  Tlie  ones  now  commonly  employed  are  called  the  knee-jerk 
or  patella  reflex;  the  peroneal  reflex;  the  foot  clonus;  and  the  tendo- 
Achilles  reflex.  The  method  of  obtaining  these  reflexes  in  the  most 
satisfactory  manner  will  be  described  separately.  It  is  important,  how- 
ever, to  remember  one  fact  in  connection  with  them  before  deciding  as 
to  their  clinical  significance,  viz.,  that  the  reflexes  should  be  tested  on  both 
sides  and  compared  loith  each  other,  because  any  perceptible  ditterences 
between  the  two  sides  are  an  indication  of  some  pathological  lesion  of 
the  cord. 

In  exceptional  cases,  the  knee-jerk  may  be  absent  in  health.  These 
exceptions  are  not  sufficient!}'  common,  however,  to  detract  from  the 
clinical  value  of  the  test. 

*Gowers  advances  a  theory  to  explain  this  fact,  which  is  certainly  ingenious  and 
possibly  its  true  interpretation.  He  starts  with  the  assumption  that  the  corpora  quadri- 
gemina,  or  the  optic  thalami  contain  a  centre  which  inhibits  or  restrains  tlie  manifestation 
of  the  skin  reflexes  in  man,  as  the  optic  lobes  have  been  proven  to  do  in  the  frog.  He 
assumes,  in  the  second  place,  that  the  higher  or  motor  centres  of  the  cerebral  cortex  are 
capable  in  health  of  overpowering  or  controlling  in  some  way  this  centre. 

Now,  if  the  motor  centres  are  prevented  from  exercising  this  function  (by  becoming 
themselves  diseased  or  mechanically  separated  from  the  fibres  that  are  functionally  asso- 
ciated with  them,  as  in  the  case  of  apoplexy,  softening  of  the  brain  substance,  tumors, 
etc.)  the  centre  which  inhibits  the  skin  reflexes  is  enabled  to  act  without  restraint,  thus 
causing  them  to  become  abolished.  On  the  other  hand,  when  the  motor  paralysis  is  due 
to  some  lesion  of  the  spinal  cord,  the  fibres  through  which  the  inhibiting  centre  acts  upon 
the  spinal  segments  below  the  seat  of  the  spinal  lesion  are  severed;  hence  the  skin  reflexes 
are  no  longer  controlled  by  the  higher  centres,  and  are  therefore  enabled  to  respond  to  even 
more  delicate  tests  than  in  health. 


THE   SPINAL   REFLEXES.  173 

The  knee-jerk  has  for  years  been  recognized  and  employed  by 
Charcot  in  diagnosis,  although  it  was  first  systematically  investigated  as 
a  clinical  symptom  by  Westphal  and  Erb.  Gowers  remarks  in  a  late 
work:  "It  is  not  a  little  curious  that  this  knee-jerk,  which  for  genera- 
tions has  amused  school-bo^s,  should  have  become  an  important  clinical 
symptom." 

To  properly  test  this  reflex  movement  of  the  limb,  the  muscles  of 
the  quadriceps  extensor  tendon  must  be  put  upon  the  stretch  to  a  mod- 
erate degree,  and  the  leg  be  unrestricted  in  its  ability  to  respond.  The 
common  method  employed  is  to  have  the  patient  cross  the  leg  over  the 
knee  and  allow  it  to  hang  passively  at  an  angle  of  nearlj^  ninety  degrees. 
Perhaps  a  still  better  way,  is  that  emploj^ed  by  Gowers,  viz.,  to  allow  it 
to  hang  over  the  forearm  of  the  physician  when  his  hand  is  placed  upon 
the  opposite  knee  of  the  patient;  because  in  this  way  the  jerk  is  often 
elicited  in  stout  people  when  it  otherwise  fails.  The  space  between  the 
patella  and  the  tibia  is  then  struck  with  a  percussion  hammer  or  the  side 
of  the  phj^sician's  hand,  upon  the  bai-e  skin,  with  sufficient  force  to  slightly 
increase  the  state  of  muscular  tension  which  has  resulted  from  flexion  of 
the  leg.  This  will  cause  a  reflex  contraction  of  the  quadriceps  extensor 
muscle  and  the  foot  will  be  jerked  upward  without  the  volition  of  the 
patient  as  a  factor  in  the  movement. 

The  ankle-jerk.  If  the  muscles  of  the  tendo-Achilles  be  put  upon 
the  stretch  by  flexion  of  the  foot,  a  blow  upon  that  tendon  will  cause  a 
similar  extension  of  the  foot. 

Tlie  foot-clonus.  When  the  excitability  of  the  cord  is  excessive,  if 
the  foot  be  firmly  flexed  and  held  so  by  the  pressure  of  the  hand  against 
the  sole,  a  series  of  rhythmical  reflex  movements  of  extension  follows, 
which  vary  between  six  and  ten  per  second.  They  can  be  traced  upon  a 
revolving  drum,  by  attaching  a  pencil  to  the  foot,  as  easily  as  a  sphygmo- 
graphic  tracing  is  made.  This  clonus  is  more  apparent  when  the  knee  is 
firmly  extended  than  when  flexed. 

The  peroneal  reflex.  The  tendons  of  the  peroneal  muscles  pass  to 
the  bones  of  the  foot  at  the  outer  side  of  the  ankle.  A  blow  made  upon 
them  when  the  foot  is  bent  inward  so  as  to  produce  a  moderate  degree  of 
tension  of  these  muscles,  will  elicit  a  reflex  movement,  as  in  the  case  of 
the  patella  tendon. 

The  '"'■  front-tap  contraction.''''  Gowers  has  described  a  reflex  test  for 
increased  spinal  irritability  that  he  considers  particularly  delicate.  It 
consists  in  flexing  the  foot  with  the  hand  upon  the  sole,  the  knee  being 
extended,  and  applying  the  blow  to  the  muscles  on  the  anterior  aspect  of 
the  leg.  It  is  followed  b}^  a  reflex  contraction  of  the  muscles  of  the 
tendo-Achilles,  which  are  not  directly  affected  by  the  blow. 

Although  the  deep  reflexes  are  commonly  tested  only  in  the  lower 


^^^  LECTURES   ON   NERVOUS   DISEASES. 

extremities,  the  same  jdicnomena  may  be  elicited  in  the  triceps  or  biceps 
muscle  of  the  arm  as  in  those  of  the  thigh  and  calf,  if  subjected  to  the 
necessary  [josition  to  insure  tension  of  the  muscles  before  the  tap  is  given 
over  the  tendon. 

Let  us  attempt  to  summarize  the  more  important  clinical  deductions 
pertaining  to  these  deep  spinal  reflexes, 

1.  A  persistent  foot-clonus  never  occurs  in  health.  It  indicates 
that  the  lateral  columns  of  the  cord  are  probably  involved  by  some 
spinal  lesion.  In  suj^posed  hysterical  affections  this  symptom  will  often 
decide  the  question  of  the  existence  of  organic  disease.  It  must  not  be 
mistaken  for  the  involuntary  foot-clonus  which  sometimes  occurs  when 
an  unnatural  posture  is  long  maintained,  even  in  health.  It  is  usually 
associated  with  exaggeration  of  all  the  other  deep  reflexes. 

2.  All  reflex  tests  become  abolished  when  the  muscles  are  separated 
from  their  connection  with  the  spinal  cord;  hence,  severing  of  a  nerve, 
posterior  spinal  sclerosis,  compression  of  the  spinal  nerve  roots,  de- 
struction of  the  gray  matter  of  the  cord,  poisons,  etc.,  are  often  associ- 
ated with  their  complete  abolition. 

3.  Disease  of  the  lateral  columns  usualh'  decreases  the  skin  reflexes, 
especially  those  of  the  trunk.  This  is  particularly  true  of  the  so-called 
descending  degeneration  of  these  columns,  which  follows  the  development 
of  cerebral  lesions. 

4.  Sclerosis  of  the  lateral  columns  always  increases  the  "deep"  or 
tendon  reflexes. 

5.  When  marked  incoordination  of  movements  is  present  and  the 
deep  7'eflexes  are  not  abolished,  it  indicates  that  sclerosis  of  the  lateral 
columns  probably  co-exists  with  similar  changes  in  Burdach's  columns. 

6.  Spasm  is  a  marked  symptom  in  many  diseases  of  the  spinal  cord. 
It  commonly  indicates  an  excessive  action  of  the  reflex  motor  centres. 
It  is  particularly  common  as  an  acute  symptom  in  spinal  meningitis.  In 
chronic  organic  diseases  of  the  cord,  it  assumes  the  form  of  contracture 
of  muscles,  especially  if  the  lateral  columns  of  the  cord  are  attacked;  this 
condition  becomes  transformed  into  that  of  a  genuine  spasm  when  the 
slightest  forms  of  peripheral  impressions  are  experienced,  as  in  delicatel}' 
manipulating  the  muscles,  for  example. 

The  Organic  Reflexes. —  Tlie  Bladder  and  Rectum. — The  bladder 
and  rectum  are  more  or  less  afljeeted,  in  respect  to  the  performance  of 
their  functions,  by  those  diseases  of  the  spinal  cord  that  tend  to  impair 
or  destroy  the  special  nervous  mechanism  connected  with  them.  Th6 
nocturnal  incontinence  of  children,  who  "wet  the  bed"  in  spite  of  all  pre- 
cautions against  the  accident,  is  an  evidence  either  of  spasm  of  the 
bladder,  excessive  stimulation  of  the  centripetal  nerves  connected  with 
the   so-called   "vesical   centres"  of  the   spinal   cord,  or   atony  of  the 


THE   OKGANIC  KEFLEXES. 


175 


sphincter  muscle.  If  due  to  spasm,  it  may  be  excited  by  worms  in  the 
intestine.  When  the  spinal  cord  is  subjected  to  sudden  injury  low  down, 
or  is  attacked  by  some  disease  process  that  involves  the  lumbar  region  of 
the  spinal  cord,  the  bladder  and  the  rectum  are  liable  to  be  paralyzed.  In 
such  cases,  if  the  paralj'sis  be  complete,  the  urine  has  to  be  drawn  with  a 
catheter.  Sometimes,  if  not  drawn  at  regular  intervals,  it  overflows, 
when  the  bladder  becomes  excessivel}'  distended.  This  compels  the  pa- 
tient to  wear  some  form  of  apparatus  to  prevent  wetting  of  the  clothing. 
Urinal  overflow  should  never  mislead  the  physician  into  the  belief  that 
the  bladder  is  empty. 

True  incontinence  is  a  rare  condition  in  the  adult.  The  term  "in- 
continence "  is  not,  however,  restricted  by  many  authors  to  that  con- 
dition characterized  by  a  continued  escape  of  urine  and  emptiness  of  the 
bladder, 

Bramwell  gives  the  following  table,  as  an  aid  in  the  diagnosis  of  two 
forms  of  incontinence  that  are  commonly  recognized  : — 


• 

Occurrence. 

Effect    of  ef- 
fort^ cough- 
ins,  ^tc. 

Age. 

Urine. 

Associated  nerve-     Effect  of 
symJ>to)ns.          Treatment. 

Spasmodic      ) 
Incontinence.  J 

Occasional  and 
intermittent. 

Nil. 

Generally 
young. 

Clear,  acid, 
and  nor- 
mal. 

None,  unless 
hysteria 

Good. 

Paralytic    J 
Incontinence.  | 

Constant. 

Forces  away 
urine. 

Any  age ; 
but    gener- 
ally old  age. 

May  be  am- 
moniacal 
and  puru- 
lent. 

If  central,  gener- 
ally a  similar 
affection  of  rectum 
and  paraplegia. 

Very  often 
unfavor- 
able. 

In  all  cases,  where  either  incontinence  or  retention  of  urine  is  de- 
veloped in  connection  with  abnormal  nerve  symptoms,  the  urethra  and 
rectum  should  always  be  carefullj-  explored  for  tlie  purpose  of  detecting 
disease,  or  of  eliminating,  if  absent,  all  local  causes  of  these  conditions. 

The  Sexual  Reflex. — In  the  lumbar  region  of  the  spinal  cord  a 
centre  is  situated  that  governs  the  acts  of  erection  and  seminal  ejacula- 
tion. It  may  be  called  into  action  either  b}'  impressions  made  upon  the 
sensory  nerves  of  the  skin  of  certain  regions,  or  b}'  cerebral  influences 
that  are  exerted  upon  the  sexual  centre  as  the  result  of  some  emotional 
impulse. 

Destructive  processes  in  this  centre  of  the  spinal  cord  cause  a  loss 
of  power  of  erection  and  ejaculation, — i.e..,  impotence.  General  spinal 
weakness  from  any  cause  may  also  lessen  the  duration  and  degree  of  erec- 
tion or  render  ejaculation  premature. 

Linked  with  some  forms  of  nervous  disease  comes  priapism,  or  the 
state  of  erection  without  sexual  desire.  It  may  be  a  result  of  irritation 
or  excessive  stimulation  of  the  following  structures:   (1)  the  sensory 


176  LECTUKES   ON   NEEVOUS  DISEASES. 

nerves  (as  in  gonorrhoea);  (2)  the  sexual  centre  itself;  (3)  the  nerves 
that  convey  the  emotional  impulses  from  the  hrain  to  the  sexual  centre 
through  the  spinal  cord;  (4)  the  parts  of  the  cerebral  cortex  functionally 
associated  with  sexual  emotions.  The  latter  are,  as  yet,  undetermined. 
Priapism  may  be  complete  and  painful,  or  incomplete  and  painless.  It 
may  last  for  days.  It  occurs  not  infrequently  in  connection  with  disease 
in  the  lower  cervical  or  upper  dorsal  regions  of  the  spinal  cord. 

The  Pupillary  Reflex. — The  last  two  cervical  and  the  three  upper 
dorsal  segments  of  the  spinal  cord  probabh*  embrace  the  so-called  "  cilio- 
spival  centre.''^  From  it  S3'mpathetic  nerves  pass  to  the  muscular  fibres 
of  the  iris.  Irritation  of  this  centre  causes  the  pupil  to  dilate;  destruc- 
tion oi  it  causes  the  pupil  to  contract.  The  tests  for  the  "Robertson 
pupil"  have  been  described  already  (p.  120).  This  peculiar  condition  of 
the  pupil  is  one  of  the  most  valuable  signs  of  the  disease  called  "  loco- 
motor ataxia  "  or  posterior  spinal  sclerosis.  It  is  the  only  condition  of 
the  eye  that  allows  of  the  movements  of  the  pupil  in  attempts  to  focus 
near  objects  and  destroj'S  at  the  same  time  the  response  of  the  pupil  to 
varying  degrees  of  light. 

TESTS   FOE   MOTOE   PAEALYSIS. 

As  mentioned  in  preceding  pages,  the  physician  maj-  be  called  upon 
to  recognize  five  forms  of  paralysis  of  motion  in  the  trunk  and  extremi- 
ties viz. :  monoplegia,  hemiplegia,  paraplegia,  hemiparaplegia,  and  com- 
plete paralysis.  If  the  paralysis  be  of  an  incomplete  or  partial  form  in 
any  type,  it  is  called  "paresis." 

Cerebral  diseases  commonly  produce  either  vionoplegia  or  hemi- 
plegia of  the  opposite  side  of  the  body,  in  case  paralysis  occurs  either 
as  a  result  of  localized  pressure  upon  the  brain  or  of  destruction  of  some 
of  its  component  fibres. 

In  those  cases  where  the  lesion  involves  both  hemispheres,  the  paral- 
ysis may  be  bilateral.  Such  lesions  are  generally  present  at  the  base  of 
the  brain. 

When  "crossed  paralysis"  is  developed,  definite  information  is 
afi"orded  respecting  the  seat  and  extent  of  the  lesion. 

Spinal  paralysis  is  bilateral  in  the  great  majority  of  cases,  and  is 
limited  to  the  muscles  of  the  legs  (paraplegia).  This  is  to  be  explained 
(1)  by  the  fact  that  the  motor  tracts  of  the  spinal  cord  are  in  a  some- 
what close  relation  to  each  other,  and  that  acute  diseases  are  seldom 
confined  to  one  lateral  half  of  the  cord ,  and  (2)  to  the  fact  that  the 
muscles  below  the  seat  of  the  lesion  are  necessarily  paralyzed  in  propor- 
tion to  the  amoimt  of  injury  sustained  by  the  motor  fibres. 

In  those  rare  cases,  where  the  spinal  lesion  is  situated  aboA'e  the 
point  at  which  the  nerves  to  the  upper  extremities  are  given  ofl",  bilateral 


TESTS   FOR   MOTOR   PARALYSIS.  177 

paralj-sis  is  apparent  in  both  extremities  (arms  and  legs),  constituting 
the  condition  termed  "  cervical  paraplegia  "  by  some  authors. 

The  points  to  be  tested  in  an}'  case  of  motor  paralysis  have  been 
enumerated  in  a  preceding  table.  Without  further  explanation,  we  will 
now  proceed  to  consider  each  separatel3\ 

The  Seat  and  Limits  of  the  Paralysis. — To  ascertain  the  exact 
limits  of  the  paralysis  is  important  as  an  aid  in  the  determination  of  the 
seat  of  the  exciting  lesion,  be  it  cerebral  or  spinal.  The  peculiarities  of 
attitude  and  gait  will  often  aid,  in  a  rough  and  imperfect  way,  in  deciding 
as  to  the  muscles  that  are  chiefly  affected ;  but  a  more  detailed  examina- 
tion of  the  separate  muscles,  by  instructing  the  patient  to  pe?-form  desig- 
nated movements  that  shall  call  different  sets  successively  into  action,  will 
be  more  accurate  and  scientific.  To  employ  these  tests  in  a  skillful 
manner,  however,  the  physician  must  first  be  thoroughly  familiar  with 
the  action  of  the  various  muscles,  both  individually  and  in  conjunction 
with  others. 


FjG.og. The  Dynamometer  of  Matthieu.   When  taken  in  the  hand  and  pressed,  the  two  sides 

of  the  elliptical  spring,  a,  i,  are  approximated,  and  the  finger  of  the  dial  records  the  exact 
amount  of  force  exerted  upon  the  spring.  One  advantage  of  this  instrument  overall  other 
devices  of  a  simijar  kind  is,  that  the  index  does  not  return  to  zero,  but  remains  at  the  point 
indicating  the  greatest  amount  of  force  exerted  by  the  hand  of  the  patient.  It  is  not  ncces- 
sarj',  therefore,  to  watch  the  index  while  the  instrument  is  being  used.  Both  hands  should 
be  tested  separately  and  the  results  noted  in  the  record  of  each  case.  A  modification  of  this 
instrument  has  been  devised  to  test  the  power  of  the  muscles  of  the  lower  extremity. 

In  some  forms  of  spinal  diseases,  where  great  accuracy  in  the  diag- 
nosis and  localization  of  the  lesion  is  required,  it  maj^  become  necessary 
to  test  the  motor  condition  of  the  various  spinal  segments  by  means  of  the 
muscles  that  are  governed  by  them.  The  investigations  of  Yeo  and 
Ferrier  upon  the  monkey  tribe,  as  well  as  those  of  Marcacci  and  Bert 
upon  dogs  and  cats,  seem  to  have  demonstrated  that  each  pair  of  spinal 
nerves  exerts  an  influence  upon  definite  muscular  movements. 

The  Degree  of  Motor  Paralysis. — Complete  paralysis,  of  course, 
abolishes  all  power  in  the  muscles  aflfected,  but  paresis  does  not,  and 
therefore  varies  in  degree.  It  is  often  important  to  decide  as  to  the 
force  that  can  be  exerted  by  the  partially  paralyzed  muscles  before  com- 
pleting a  diagnosis.  This  can  be  best  accomplished  in  the  muscles  of 
the  upper  extremity,  by  the  emploj-ment  of  an  instrument  devised  by 
Matthieu,  an  instrument-maker  of  Paris,  called  the  dynamometer.  It  is 
shown  in  the  cut. 

12 


178 


LECTUKES   ON   NERVOUS   DISEASES. 


When  grasped  in  the  hand,  the  index  shows  the  amount  of  power 
that  is  exerted  upon  the  spring.  The  index  remains  fixed  until  mecliani- 
cally  rephiced  after  it  has  been  used ;  this  enables  the  physician  to  direct 
his  attention  to  other  points  in  the  case  while  the  patient  is  tr^'ing  his 
muscles.  It  is  really  a  test  for  the  "grasping  power"  of  the  flexor 
muscles  of  the  forearm  onlj\  An  apparatus  for  tracing  the  effects  of 
muscular  contraction  is  sometimes  attached  to  the  dynamometer.  It  is 
called  the  dynamograph.     It  shows  irregularities  of  muscular  contraction. 


Fig.  57. — The  Dynamograph. — This  modification  of  the  dynamometer  enables  the  physician 
to  observe  and  record  the  condition  of  the  muscles  in  respect  to  their  ability  to  maintain 
tonic  contractions.  In  health,  the  line  drawn  by  the  pencil  should  be  per/fctly  straight 
when  the  elliptical  spring  is  steadily  compressed  by  the  hand  for  a  few  seconds.  If  the 
grasping  power  is  intermittent  or  incapable  of  being  maintained  continuously  for  an  interval 
of  several  seconds,  the  line  described  on  the  recording  tablet  will  be  irregular.  The  slips  of 
paper,  indicating  the  deviations  of  the  pencil,  can  be  preserved  in  the  case-book,  and  by  com- 
parison they  laay  show  improvement  or  increase  of  the  muscular  debility. 

The  strength  of  the  muscles  of  the  calf  can  be  tested,  as  Gowers 
suggests  by  requesting  the  patient  to  jump  on  tip-toe.  And  also  bj-  an 
ingenious  instrument  devised  by  Dr.  Birdsall,  of  this  city,  called  the 
"  foot-dynamometer. " 

A  third  method  of  testing  the  various  muscles  is  to  request  the 
patient  to  exercise  all  possible  resistance  to  some  special  movements  that 
the  physician  creates  by  manipulation;  or,  on  the  other  hand,  to  request 
the  patient  to  perform  some  special  movement  and  estimate  the  amount 
of  force  required  to  prevent  his  doing  so. 

Bilateral  paralysis  requires  that  the  power  of  the  muscles  should  be 
compared  with  that  of  a  healthy  individual  of  about  the  same  muscular 


THE   TROPHIC    CONDITION    OF   THE   MUSCLES.  179 

development  as  the  patient,  if  great  accuracy  is  desired.     In  unilateral 
paralysis,  the  healthy  side  can  be  used  as  a  standard  of  comparison. 

THE  TEOPHIC   CONDITION   OF   THE   MUSCLES. 

The  amount  of  atrophy  or  wasting  that  ensues  simply  from  disuse 
of  the  muscles  must  be  distinguished  from  that  due  to  a  loss  of  tlie  so- 
called  "trophic  function"  in  the  nerves  that  suppl}^  the  muscles. 

Rapid  wasting  of  a  muscle  occurs  when  the  nerve  fibres  that  supply 
it  are  cut  off  from  the  so-called  "trophic  centre"  of  the  spinal  cord  with 
which  the}^  are  normally  connected.  The  multipolar  nerve  cells  in  the 
anterior  hon^s  of  the  spinal  gray  substance  are  probably  the  "trophic  cen- 
tres "  for  the  motor  fibres  found  in  the  anterior  roots  of  each  spinal  nerve. 
When  these  cells  become  the  seat  of  disease,  the  muscles  undergo  extreme 
and  rapid  atrophy.  Similar  changes  also  occur  when  the  nerves  are  cut 
off  from  the  connection  with  them,  as  in  wounds  of  a  nerve,  pressure 
upon  a  nerve,  etc. 

THE   POWER   OF   COORDINATION   OF   MUSCULAR   MOVEMENTS. 

Disease  of  the  cerebellum,  the  lemniscus  or  fillet-tract  (Fig.  11), 
and  of  the  columns  of  Burdach  and  GoU  in  the  spinal  cord  (see  Fig.  32) 
is  commonly  associated  with  a  peculiar  inability  on  the  part  of  the 
patient  to  perform  certain  muscular  movements  in  a  jjroper  way, 
because  the  muscles  do  not  act  in  the  sequence  necessary  to  accomplish 
them.     This  is  termed  "incoordination  of  movement." 

Various  tests  are  employed  in  determining  the  degree  of  this  ab- 
normal state,  because  one  that  will  answer  for  the  lower  limbs  will  not 
for  the  upper  extremities,  or  vice  versa.  Besides,  it  is  necessary  in  these 
cases  to  decide  both  as  to  the  ability  to  perform  complex  movements 
with  accuracy,  and  also  as  to  the  state  of  the  so-called  "muscular  sense." 
Let  us  consider  first  the  tests  of  the  former. 

When  so-called  "ataxic  patients"  are  requested  to  follow  a  designated 
line  in  the  floor  or  carpet  as  they  walk  across  a  room,  they  invariably 
keep  their  eyes  fixed  upon  the  floor,  and  have  extreme  difficulty  in  fol- 
lowing the  line.  Now,  ask  such  a  patient  to  do  the  same  with  the  eyes 
looking  straight  ahead  of  him,  and  the  attempt  will  prove  a  still  more 
lamentable  failure  than  before.  In  advanced  stages  of  the  disease,  the 
patient  may  fall. 

A  second  manifestation  of  lack  of  coordination  in  the  muscles  of  the 
legs  lies  in  an  inability  on  the  part  of  the  patient  to  stand  erect  with  the 
feet  in  close  contact,  without  swaying  or  falling.  This  is  rendered  still 
more  difficult  when  the  patient  is  instructed  to  close  the  eyes.  It  must 
be  remembered,  however,  that  an  inabilitj'^  to  stand  erect  and  motion- 
less with  the  eyes  closed  is  not  always  due  to  ataxia.     I  have  seen  the 


180  LECTUKES     ON     NERVOUS    DISEASES. 

same  result  produced  artificially  in  a  healthy  subject  hy  freezing  the 
soles  of  the  feet  to  a  degree  suflicient  to  destroy  the  appreciation  of  its 
contact  with  the  floor  or  carpet.  The  test  is  a  reliable  one  only  for  the 
presence  of  marked  anaesthesia  of  the  soles  of  the  feet;  hence  it  is  common 
in  ataxic  subjects,  in  whom  sensation  is  always  more  or  less  impaired. 

Considerable  stress  may  be  laid  upon  this  point,  because  it  is  stated 
b}^  some  writers  that  this  S3mptom  or  test  is  to  be  regarded  as  a 
positive  sign  of  locomotor  ataxia.  That  it  is  a  valuable  diagnostic  point 
jn  that  disease,  when  associated  with  other  evidences  of  its  existence, 
cannot  be  disputed;  but  it  is  by  no  means  a  pathognomonic  symptom,  as 
it  might  exist  in  any  disease  (cerebral,  spinal,  or  functional)  that  could 
cause  marked  anaesthesia  of  both  lower  extremities. 

In  order  to  preserve  the  equilibrium  during  an  erect  posture  when  the 
feet  are  in  close  contact,  it  is  necessary  that  the  nerves  of  sensation  allow 
the  keenest  appreciation  by  the  nerve  centres  of  variations  in  the  amount 
of  pressure  exerted  by  the  weight  of  the  subject  upon  the  different 
regions  of  the  sole  of  the  feet.  When  such  information  is  withheld  from 
any  cause  (chiefly  by  sensory  paralysis  or  anaesthesia)  the  nerve  centres 
can  no  longer  properlj'  govern  the  muscles  to  counteract  a  tendency 
toward  a  fall,  provided  that  the  sense  of  sight  is  prevented  from  giving 
them  the  necessary  information.  This  explains  why  it  is  that  ataxic 
patients  often  notice  a  difficulty  in  washing  the  face  at  a  Avashstand  when 
the  eyes  are  closed ;  wh^^  they  keep  the  vision  fixed  upon  the  ground  as 
an  aid  in  governing  the  movements  of  walking;  and  why  they  keep  their 
feet  well  apart  when  standing  still,  in  order  to  increase  their  base  of  sup- 
port. All  the  other  symptoms  of  ataxia  may  thus  be  mechanically  in- 
terpreted and  be  employed  as  tests  in  diagnosis. 

Among  these  s^-mptoms  may  be  mentioned :  a  difficult}-  in  climbing 
a  flight  of  stairs,  on  account  of  the  feats  of  balancing  required  to  do  so; 
a  difficulty  in  placing  the  foot  rapidly  and  accurately  upon  some  small 
object,  as  in  mounting  a  horse  by  means  of  the  stirrup;  and  many  others 
of  a  similar  kind. 

The  tests  for  incoordination  of  the  muscles  of  the  upper  extremity 
have  not  as  yet  been  described. 

The  handwriting  is  sometimes  seriously  aff"ected  in  ataxic  patients, 
by  an  inability  to  make  continuous  curves  with  accuracy,  as  in  the  case 
of  the  capital  letters  C,  D,  G,  etc.  This  is  because  the  acts  required  of 
the  muscles  in  making  these  curves  are  complicated  and  must  follow  each 
other  in  a  certain  sequence,  in  order  to  properly  execute  them.  Again, 
the  clothes  are  buttoned  and  unbuttoned  tcith  extreme  difficulty^  because 
these  simple  acts  require  coordinated  muscular  movements  of  a  complex 
character.  Food  and  drink  are  carried  to  the  mouth  with  difficulty  in 
some  cases,  especially  when  the  eyes  are  closed  or  in  the  dark.     These 


THE   MUSCULAR   SENSE.  181 

patients  cannot  touch  designated  parts  of  the  face  with  the  finger  with 
accuracy  and  rapidity  when  the  incoordination  of  the  upper  extremities 
is  well  developed,  or  the  so-called  "  muscular  sense  "  is  destroyed.  These 
tests  will  be  mentioned  later. 

THE   MUSCULAR   SENSE. 

B}'  this  term  we  mean  tlie  power  which  each  individual  possesses,  in 
health,  of  discriminating  in  regard  to  the  amount  of  muscular  force  re- 
quired to  accomplish  certain  ends.  Thus,  for  example,  if  two  objects  are 
held  in  the  hands,  the  difference  in  weight  between  them  should  be  esti- 
mated with  an  approach  to  accuracy.  Again,  if  the  eyes  be  closed,  the 
fingers  can  be  made  to  touch  rapidly  any  designated  portion  of  tlie  body 
with  perfect  certainty.  Movements  of  progression  should  be  also  per- 
formed with  the  eyes  closed  nearly  as  well  as  when  open,  if  the  distance 
be  short  and  the  location  a  familiar  one.  Finally,  the  handwriting  should 
not  diflfer  materially  as  regards  the  formation  of  letters  when  made  with 
the  eyes  shut  or  open. 

Now  in  some  forms  of  nervous  derangements,  the  muscular  sense  is 
impaired;  hence  it  becomes  necessary  to  sometimes  test  it  before  making 
a  final  diagnosis.  Several  tests  are  commonly  employed.  They  may  be 
designated  as  the  "weight"  test,  the  "movement"  test,  and  the  "hand- 
writing" test. 

In  testing  the  power  of  discrimination  of  weights  held  in  the  hands, 
it  is  best  to  have  them  all  of  uniform  size^  in  order  to  avoid  the  patient 
using  the  sense  of  sight  as  a  factor  in  his  decision.  Hanging  different 
weights  from  the  foot  in  a  handkerchief  will  test  the  muscular  sense  in 
the  lower  extremity.  Metallic  balls  of  different  thickness  but  of  uniform 
size,  either  covered  or  uncovered,  answer  the  purposes  of  the  "weight" 
test.  The  ability  on  the  part  of  a  patient  to  tell  with  the  eyes  closed  the 
exact  position  of  a  limb  in  reference  to  other  parts  of  his  bodiy,  when 
different  attitudes  are  assumed,  may  be  interpreted  as  an  exhibition  of 
the  muscular  sense. 

To  test  the  accuracy  of  movement,  direct  the  patient  to  close  the 
eyes  tightly,  or  blindfold  him,  and  then  instruct  him  to  rapidly  place  the 
forefinger  of  either  hand  alternately  on  some  spot  upon  his  body  which 
shall  be  designated  in  each  instance,  as  the  nose,  upper  lip,  lower  lip,  ear 
of  either  side,  etc.  When  the  lower  limbs  are  to  be  tested,  he  may  be  in- 
structed to  place  his  great  toe  upon  the  opposite  instep,  heel,  knee-cap, 
etc.,  or  to  raise  the  foot  to  a  given  height  when  lying  on  the  back,  and 
then  to  slowly  lower  it  till  it  rests  upon  some  designated  spot  on  the 
other  foot. 

The  handwriting  of  a  patient  is  often  of  value  in  diagnosis;  es- 
pecially when  a  sentence  written  with  the  eyes  open  is  compared  with 


182  LECTUEES   ON  NERVOUS   DISEASES. 

the  same  written  with  the  eyes  closed.  In  health  the  muscular  sense 
should  enable  almost  any  one  to  perform  Loth  with  a  fair  degree  of  pre- 
cision. In  motor  paralysis  or  ataxia  the  changes  are  marked,  especially 
in  the  latter,  because  incoordination  of  the  muscles  prevents  the  forma- 
tion of  continuous  and  well-formed  curves,  even  when  the  ej'es  are  open, 
and  utterly  desti'oys  the  legibilit}^  of  the  letters  if  closed.  The  exist- 
ence of  tremor,  or  the  presence  of  profound  motor  paral3'sis,  will,  of 
course,  interfere  most  seriously  with  the  ability  of  the  patient  to  write 
legibly,  if  at  all,  irrespective  of  the  aid  of  vision. 

TESTS   TO   DETERMINE   THE   IRRITABILITY   OF   THE   MUSCLES. 

In  some  forms  of  cerebral  and  spinal  disease  it  becomes  necessary 
to  test  the  so-called  "irritability"  of  the  muscles.  Two  forms  of  tests 
are  employed  for  this  purpose,  viz.,  mechanical  and  electric. 

Mechanical  tests  enable  us  to  decide  (1)  as  to  the  existence  of  dimin- 
ished or  increased  tension  of  the  muscles;  (2)  the  j^^fsence  of  twitchings 
of  individual  muscular  fibres  in  certain  regions  (as  if  a  live  animal  were 
imprisoned  beneath  the  skin);  (3)  the  presence  of  tremor:  and  (4)  the 
state  of  muscular  rigidity  and  permanent  shortening  known  as  '■'con- 
tracture.''^ 

Electric  currents  are  employed  as  aids  in  diagnosis,  chiefly  in  de- 
ciding the  question  of  the  existence  of  degenerative  changes  in  the  mus- 
cles. The  increase  or  decrease  of  such  changes,  when  they  have  been 
found  to  exist,  can  also  be  scientifically  determined  b}-  the  emploj^ment 
of  electric  tests  from  time  to  time. 

MECHANICAL   IRRITABILITY   OF   THE   MUSCLES. 

When  the  muscles  are  subjected  either  to  manipulation,  a  light 
tapping  with  the  tip  of  the  finger,  or  a  stroke  with  a  percussion  hammer, 
either  an  abnormal  exaggeration  or  a  diminution  of  the  mechanical  ex- 
citability of  the  pai't  struck  is  sometimes  detected  in  connection  with 
disease  or  injury  of  the  brain,  the  spinal  cord,  or  of  the  nerves  themselves. 

The  following  clinical  deductions  are  offered  as  a  summary  of  these 
tests : — 

1.  Motor  paralysis  usually  decreases  the  mechanical  excitability  of 
the  muscles  affected. 

2.  When  the  '' galvanic  excitability''''  is  markedly-  increased  (reac- 
tion of  degeneration)  the  mechanical  excitability  of  the  muscles  is  also 
increased. 

3.  A  marked  increase  in  the  ^^ deep''''  or  ^^ tendon  reflexes'^  is  like- 
wise associated  with  an  increase  in  the  mechanical  excitability  of  muscles. 
This  is  particularly  characteristic  of  sclerosis  or  hardening  of  the  lateral 
columns  of  the  spinal  cord. 


LESIONS   OF  THE   CENTRUM   OVALE.  183 

4.  Atrophy^  or  ivasting  of  the  muscles^  as  the  resnlt  of  disease-pro- 
cesses, such  as  functional  paralysis,  poliomyelitis,  etc.,  usually  tends  to 
diminish  the  tonicity  of  the  affected  muscles  (state  of  flacciditj-).  An 
exception  to  this  rule  exists  for  a  time  in  am5'Otrophic  lateral  sclerosis 
and  other  conditions  where  marked  muscular  rigidity  precedes  the 
atrophy-. 

5.  Any  disease  that  tends  to  cause  irritation  of  the  motor  verve- 
fibres,  or  to  arrest  the  control  of  the  brain  over  the  spinal  segments,  is 
liable  to  be  associated  with  rigidity  of  the  muscles.  Twitchings,  mus- 
cular cramps,  tremors,  spasms,  and  contractures,  may  be  associated  with 
this  increase  of  muscular  tension. 

The  distribution  of  the  muscular  rigidity  differs  if  the  exciting 
cause  be  confined  to  the  spinal  coverings  or  the  substance  of  the  cord 
itself.  In  the  former  case  the  flexors  are  chiefly  involved.  Hard- 
ening or  sclerosis  of  the  lateral  columns  of  the  cord  usually  causes  the 
lower  limbs  to  be  firmly  extended  and  closely  approximated  to  each 
other. 

6.  The  disease  known  as  "  progressive  muscular  atrophy "  is  the 
one  most  commonly  associated  with  contractions  of  separate  fibres  or 
bundles  of  fibres  in  the  muscles, — the  so-called  '■'■fibrillary  twitchings.^'' 
These  twitchings  are  not  confined,  however,  to  this  condition.  Hj-po- 
chondriacs  and  certain  functional  diseases  of  the  spinal  cord  maj^  also  be 
associated  with  them.  A  slow  destructive  process  affecting  the  motor 
nerve-cells,  or  the  motor  nerves  themselves,  may  also  cause  them. 

7.  A  permanent  shortening  of  muscles  (state  of  contracture)  is  a 
frequent  sequel  to  extensive  atrophy  or  wasting  of  the  muscular  fibres. 
It  may  result  also  from  the  prolonged  and  unrestrained  action  of  certain 
muscles  whose  antagonists  are  lacking  in  muscular  power,  as  in  the  case 
of  infantile  paralysis,  lateral  sclerosis,  etc. 

TESTS   EMPLOYED   IN   THE   DIAGNOSIS   OF    LESIONS    OF    THE   WHITE 
SUBSTANCE   OF   THE   CEREBRAL   HEMISPHERES. 

Lesions  of  the  centrum  ovale  have  always  been  regarded  as  pecu- 
liarly difficult  of  detection  and  localization  during  life.  In  quite  a  large 
proportion  of  cases  where  extensive  disease  of  this  portion  of  the  brain 
has  been  discovered  after  death,  the  presence  of  the  lesion  has  been 
either  unsuspected  during  life,  or,  if  suspected,  imperfectly  localized. 
The  fibres  which  assist  to  form  the  white  substance  of  the  brain  comprise 
the  commissural,  associating,  and  peduncular  tracts.  These  have  been 
described  already  on  page  17.  Dr.  M,  A.  Starr  has  lately  written  a 
very  interesting  and  lucid  article  upon  lesions  of  the  centrum  ovale 
{3Ied.  Record,  Feb.,  1886).  He  explains  how  a  severance  of  the  "com- 
missural" and  "associating  tracts'"  of  the  cerebral  hemisphere  maybe 


184  LECTURES   ON   NERVOUS   DISEASES. 

recognized  duriiiiz;  life  by  a  careful  examination  of  the  mental  faculties  of 
the  imtient  an<l  by  testing  the  ability  of  the  patient  to  perform  identical 
and  simultaneous  bilateral  movements  of  the  face  and  the  extremities. 
The  tests  designated  by  this  author  may  be  summarized  as  follows  : — 
To  Test  the  Commissural  Fibres. — If  the  two  hands  are  moved  in 
unison,  during  attempts  to  draw  a  circle  or  write  one's  name  with  each 
hand  simultaneoush',  the  right  hand  should  move  to  the  right  to  exactly 
the  same  extent  as  the  left  hand  does  to  the  left.  Therefore,  although 
the  writing  of  the  right  hand  is  legible,  that  of  the  left  hand  will  be 
backwards  and  can  be  easil}-  read  only  by  the  aid  of  a  mirror  ("  mirrcr- 
writing"  test).  Whenever  simultaneous  bilateral  movements  are  found 
to  be  defective,  the  "commissural"  fibres  (Fig.  6)  will  probably  be  found 
to  be  congenitally  imperfect  or  impaired  by  a  morbid  lesion.  The  history 
of  the  patient  would  decide  which  of  these  two  probably  existed  in  any 
given  case.  On  this  principle,  bilateral  movements  of  the  upper  and 
lower  limbs  can  be  tested  in  a  variety'  of  ways. 

The  Tests  for  the  "Associatixg-tracts''  are  somewhat  more  com- 
plex— although  they  are  by  no  means  difficult  to  understand.  The  fol- 
lowing suggestions  are  pertinent  to  this  field  : — 

1.  To  test  the  connection  between  the  hearing  centres  and  Broca's  speech  centre 
(temporo-frontal  tract).  Request  the  patient  to  repeat  promptly  words  dictated 
to  him.  Notice  also  if  any  impairment  of  spoken  language  exists  during  a  con- 
tinued conversation. 

2.  To  test  the  tract  between  the  hearing  and  sight  centres  (occipito-temporal  tract). 
Ascertain  if  the  patient  can  read  intelligibly  to  himself  and  afterwards  tell  cor- 
rectly what  he  has  read. 

3.  To  test  the  "  ocdpito-temporo-frontal  tract."  Ask  the  patient  to  read  aloud  some 
selected  paragraphs. 

4.  To  test  the  tract  which  unites  the  sight  centres  with  the  motor  centres  (occipito- 
central  tract).     Ask  the  patient  to  write  what  a  selected  paragraph  contains. 

5.  To  test  the  tract  which  unites  the  hearing  centres  with  the  motor  centres 
(temporo-central  tract)<.     Request  the  patient  to  write  from  dictation. 

6.  To  further  test  the  tract  uniting  the  sight  and  hearing  centres  with  the  speech 
centres.  Ask  the  patient  to  name  the  color  of  different  bbjects  placed  in  his 
field  of  vision;   also  their  form  and  general  appearance. 

7.  To  test  the  tract  connecting  the  frontal  convolutions  and  the  motor  centres 
(fronto-central  tract).  Request  the  patient  to  write  what  he  speaks  to  himself — 
preferably  in  an  audible  whisper,  so  that  the  observer  can  detect  an  error. 

8.  To  test  the  tract  connecting  the  smell  and  taste  centres  with  the  hearing  and 
speech  centres  (the  hippocampo-temporo-frontal  tract).  Request  the  patient  to 
speak  the  names  of  particular  odors  or  tastes,  of  which  he  may  be  made  cogni- 
zant during  the  interview  by  the  physician  or  an  attendant. 

9.  To  test  the  connections  between  the  smell,  taste  and  hearing  centres  with  the 
motor  centres  (the  hippocampo-temporo-central  tract).  Request  the  patient  to 
write  the  names  of  odors  or  taste-impressions,  of  which  he  may  be  made  cogni- 
zant at  the  time  by  the  observers. 


THE   PRINCIPLES   OF   ELECTRO-DIAGNOSIS.  185 

After  such  tests,  as  those  described,  have  been  carefully  made,  all 
forms  of  impairment  of  the  various  tracts  observed  may  be  contrasted, 
and  thus  be  made  a  basis  for  a  diagnosis  of  a  lesion  of  tlie  white  sub- 
stance of  the  hemispheres.  Some  knowledge  of  the  anatomical  relations 
of  the  various  associating  and  commissural  tracts  is  of  course  necessary 
in  order  to  form  the  proper  deductions  respecting  an  individual  case. 

It  should  be  remembered  : — 

1.  That  the  '■"  occipito-temporaV  tract  lies  in  close  relationship  with 
the  fibres  of  vision ;  hence,  the  symptoms  of  its  destruction  are  liable  to 
accompany  homonymous  hemianopsia  of  the  same  side  as  the  affected 
cerebral  hemisphere. 

2.  That  the  '"''  occipito-centraV  tract  lies  on  a  higher  plane  than  the 
occipito-temporal ;  hence  this  bundle  of  fibres  may  escape  a  lesion  which 
involves  the  preceding  tract ;  and  the  patient  may  retain  the  power  of 
writing  selected  paragraphs,  even  if  he  cannot  read  them  correctl  v.  Such 
a  case  as  that  reported  by  Charcot  (page  8)  illustrates  this  point  in 
diagnosis. 

3.  That  the  ^^ parieto-temporal  "  tract  is  probably  designed  to  allow 
of  the  association  between  memories  of  sensations  of  touch,  pain  and 
temperature,  with  the  memories  of  those  sounds  by  which  we  expi-ess 
such  sensations  in  words.  Patients  in  health  can  thus  announce  to 
others  whether  an  object  is  hard  or  soft,  cold  or  warm,  rough  or  smooth, 
etc. ;  and  a  lesion  of  this  tract  may  interfere  seriously  with  the  proper  ex- 
pression in  words  of  the  patient's  real  impressions  gained  by  touch. 

4.  A  perfect  connection  between  the  hearing  and  speech  centres 
(temporo-frontal  tract)  is  absolutely  essential  to  correct  speech  ;  because 
we  are  enabled  to  produce  any  desired  sounds  only  b}'  recalling  to 
memory  and  imitating  similar  sounds  whose  meaning  has  been  gradually 
acquired  by  the  ear  and  recorded  in  the  cells  of  the  cortical  area  occupied 
by  the  centres  of  hearing. 

THE  PRINCIPLES  OF  ELECTRO-DIAGNOSIS.* 
The  various  electric  tests  that  are  employed  as  aids  in  the  diagnosis 
of  nervous  affections  are  too  complex  to  be  fully  described  and  explained 
witliout  entering  somewhat  into  the  domain  of  physics  and  physiology. 
Erbf  has  lately  written  an  excellent  work  upon  the  subject,  and  most  of 
the  later  treatises  upon  physiology  will  afford  general  information  re- 
specting the  reactions  of  healthy  muscle  to  the  faradaic  and  galvanic 
currents.  The  few  practical  hints  which  are  given  here  are  offered  with 
an  apology  for  their  incompleteness,  although  it  is  hoped  that  they  will 
assist  you  in  your  studies  in  this  field. 

*  Portions  of  this  locture  have  already  been  published, 
t  "  Haudbook  of  Electro-Therapeutics,"  New  York,  1883. 


186  LECTURES   ON   NERVOUS   DISEASES. 

Having  first  moistened  the  electrodes  and  connected  them  with  the 
battery  in  action,  it  is  customary  to  hold  them  both  in  one  hand  (close 
together,  but  not  in  contact),  and  apply  them  to  the  ball  of  the  thumb  of 
the  opi)osite  hand  or  the  cheek  to  see  if  the  current  is  passing  properl3^ 
If  the  current  to  be  employed  is  a  very  weak  o«e,  touch  the  electrodes  to 
the  tip  of  the  tongue  before  it  is  used  upon  the  patient.  The  use  of  a 
reliable  milliampere-meter  will  prove  of  value  in  determining  the  exist- 
ence as  well  as  the  strength  of  a  current. 

Next,  sponge  the  part  of  the  patient's  body  to  be  tested  with  a  tceak 
solution  of  table-salt  in  warm  water,  in  order  to  render  the  skin  a  good 
conductor  of  the  electric  currents.  If  the  wire-brush  is  to  be  used,  this 
step  is  omitted. 

The  "  polar  method  "  is  the  one  commonlj^  used.  Apply  one  electrode 
of  large  size,  either  over  the  breast-bone  of  the  patient  (at  about  its  centre) 
or  over  the  back  of  the  neck.  The  breast-bone  is  the  preferable  point  on 
account  of  the  absence  of  muscles  in  the  median  line.*  The  other  elec- 
trode (of  small  size)  is  placed  over  some  special  nerve-trunk  or  the  muscle 
to  be  tested;  in  case  muscle  is  to  be  tested,  the  electrode  is  placed  usually 
at  the  point  where  the  motor  nerve  enters  its  substance, — the  so-called 
''motor-point"  of  the  muscle.  In  this  way  the  action  of  the  two  poles 
can  be  readil}'  distinguished. 

Use  both  the  continuous  or  galvanic  current  and  the  interru2:)ted  or 
faradaic  current  in  testing  muscular  reactions.  The  former  is  of  the 
greatest  value  in  diagnosis. 

In  studying  the  muscular  reactions  to  the  different  currents  emplo3'ed, 
remember  (1)  that  the  negative  pole  is  called  the  cathode  (C),f  and  the 
positive  pole  the  anode  (A);  (2)  that  muscular  contractions  occur  both 
when  the  current  is  altered  in  strength  and  when  the  circuit  is  closed  or 
opened;  (3)  that  the  faradaic  current  produces  an  apparently  continuous 
muscular  contraction,  because  its  interruptions  are  so  very  rapid;  (4) 
that  very  weak  currents  do  not  produce  contractions;  (5)  that  alterations 
in  the  strength  of  the  current  cause  proportionate  variations  in  the  con- 
tractions; (6)  that  the  contractions  are  short,  sharp,  and  sudden  in 
health;  (7)  that  the  effects  of  applying  the  electrode  over  the  substance 
of  the  muscle  and  over  its  motor  point  are  identical  in  health,  but  not  in 
some  diseased  conditions;  (8)  that  the  galvanic  current  will  not  usually 
produce  muscular  contractions  while  it  is  constant,  but  only  when  its 
strength  is  modified  or  when  the  circuit  is  closed  or  broken;  (9)  that  the 

*  This  is  known  as  the  "indifferent  point,"  when  polar  effects  are  being  studied  at 
the  other  electrode. 

t  German  authors  emploj'  different  symbols  from  those  given.  These  are  as  follows  : 
C.  C.  C.  =  Ka  S.  Z.,  C.  O.  C.  =  Ka  O.  Z.,  A.  C.  C.  =  An  8.  Z.,  A.  O.  C.  =  An  O.  Z.  The 
symbols  Ka  =  cathode,  An  ^  anode,  S  =  closure  {Schliessung'),  O,  =:  opening  (  Oeffnung) , 
Z  =  contraction  {Zuckung) . 


THE  PRINCIPLES   OF   ELECTRO-DIAGNOSIS.  187 

direction  of  the  current  can  be  changed,  without  altering  the  position  of 
the  electrodes,  by  a  simple  apparatus  that  changes  the  cathode  into  the 
anode,  and  vice  versa  (the  commutator). 

The  current  passes  always  from  the  anode  to  the  cathode.  Hence, 
when  the  positive  pole  is  placed  on  the  breast  or  neck,  and  the  other  on 
the  muscle  to  be  tested,  we  have  a  descending  current.  An  ascending 
current  exists  if  the  cathode  is  on  the  same  distant  or  neutral  point. 

An  "automatic  interrupter"  on  an  "interrupting  electrode"  is 
necessary'  in  employing  the  galvanic  current  in  testing  muscular  reac- 
tions. 

The  descending  current  (cathode  over  the  nerve  or  muscle)  when 
closed  and  again  broken  can  thus  give  us : — 

1.  The  cathodal  closure  contraction : — 

C.  C.  C.  or  Ka  S.  Z.  of  the  Germans. 

2.  The  cathodal  opening  contraction : — 

C.  O.  C.  or  Ka  0.  Z.  of  the  Germans. 

The  ascending  current  (the  poles  being  now  reversed)  when  closed 
and  again  broken  can  give  us : — 

1.  The  anodal  closure  contraction: — 

An  C.  C.  or  An  S.  Z.  of  the  Germans. 

2.  The  anodal  opening  contraction : — 

An  O.  C.  or  An  0.  Z.  of  the  Germans. 

These  four  forms  of  contraction  require  currents  of  different 
strengths  to  produce  them.  They  are.  therefore,  induced  by  gradualli/ 
increasing  the  number  of  cells  employed.  The  following  order  is  the 
only  one  commonly  observed  in  healthy  muscle : — 

1 C.   C.    C.  =  KaS.  Z. 

2 An  C.  C.  =  An  S.  Z. 

3 An  0.  C.  =  An  0.  Z. 

4 C.   0.    C.  =  Ka  0.  Z. 

It  will  be  observed  that  the  cathodal  contractions  appear  first  and 
last  in  health,  while  the  anodal  contractions  follow  each  other;  also,  that 
the  closure  contractions  precede  the  opening  contractions  of  both  tlie 
cathode  and  anode.  When  a  nerve-trunk  is  stimulated  by  electric  cur- 
rents the  formula  of  the  normal  muscular  contractions  is  altered.  This 
will  be  spoken  of  hereafter. 

Again,  as  the  strength  of  the  current  is  gradually  increased,  the  con- 
tractions which  have  successively  appeared  become  intensified  propor- 
tionately (as  is  shown  below),  and  new  reactioyis  are  added  : — 

First  stage  {moderate  current),  C.  C.  C. 

Second  stage  {stronger  current).,  C  C  C  and  An  C.  C. 


188 


LECTURES   ON  NERVOUS   DISEASES. 


Third  stage  (still  stronger  current),  C."  C"  C."  and  An'  C  C/  and 

A.  O.  C. 
Fourth  stage  {very  strong  current),  C"  C/"  C"  and  An"  C."  C." 

and  An'  0/  C  and  C.  O.  C. 
C"  C"  C"  is  called  '■'■cathodal  tetanus,''''  because  the  contraction 
is  very  violent.     Sometimes  the  anodal  contractions  both  occur 
with  the  same  intensity  of  current,  thus  merging  the  second  and 
third  stages  into  one.     Again  An  O.  C.  may  in  some  cases  appear 
before  An  C.  C. 
Disease  of  the  nerve-centres  or  of  the  nerves  themselves  may  canse 
modifications  of  the  normal  formula  of  muscular  contractions.     This  con- 
stitutes the  key-note  to  the  value  of  electric  currents  in  diagnosis.     Me- 
chanical devices  may  be  emploj^ed  to  trace  the  muscular  contractions,  as 
the  sphygmograph  does  the  pulse.     Fig.  58. 


K^t    An 


Ka-.  "'An      :  fKa    '"'An 


Ka\   'An 


Ka     An 


Fig.  5S. — Curves  of  Closure  Contractions  in  Direct  (Unipolar)  Stimulation  of  the 
Muscles  in  the  Distribution  of  the  Peroneal  Nerve  in  the  Leg.  (Erb).  Ka  = 
C.  C.  C.  ;  An  =  A.  C.  C.  1,  Curve  of  health,  thirty-three  elements  ;  C.  C.  C.  is  greater 
than  A.  C.  C.  :  2.  case  of  chronic  anterior  poliomyelitis,  showing  reaction  of  degeneration 
with  thirty-three  elements  ;  3,  same  case,  with  forty  elements.  In  2  and  3,  the  excess  of  A. 
C.  C.  over  C  C.  C  is  apparent ;  3,  in  the  slow  character  of  the  contractions  is  very  marked. 


If  the  destructive  process  is  within  the  brain  or  spinal  cord,  and 
situated  above  the  ^'^  trophic  centres''''  of  the  nerves  supplying  the  paralyzed 
muscles,  the  electrical  reactions  of  the  paralj-zed  muscles  will  be  normal 
in  respect  to  the  sequence  and  character  of  the  muscular  contractions. 


THE   PRINCIPLES    OF   ELECTEO-DIAGNOSIS.  189 

Sometimes,  however,  a  much  stronger  current  (galvanic  or  faradaic)  is 
required  to  produce  tliem  over  the  healthy  muscles.  This  fact  is  due 
to  atrophic  changes  in  the  muscles.  It  may  be  of  decided  value  in 
diagnosis. 

When  disease  processes  in  the  brain  or  spinal  cord  cause  destruction 
of  the  trophic  centres  of  the  nerves  that  supply  the  paralyzed  muscles,  or 
when  the  cet'ebro-spinal  nerves  themselves  are  seriously  injured^  we  en- 
counter what  Erb  has  described  as  the  "reaction  of  degeneration." 
This  will  require  some  explanation, 

1.  Every  nerve  degenerates  lohen  separated  from,  its  trojihic  centre; 
hence,  the  electric  excitability  of  the  nerve,  both  to  the  faradaic  and 
galvanic  currents,  gradually  diminishes  and  ceases  entirely  at  the  end  of 
about  two  weeks. 

2.  The  faradaic  current  ceases  to  cause  muscular  contractions  when 
applied  directly  over  the  substance  of  the  muscle.  This  is  explained  by 
the  fact  that  the  so-called  "nerve-plates"  within  the  substance  of  the 
muscle  are  degenerated,  and  currents  of  momentary  duration  fail  to  affect 
the  muscular  fibres. 

3.  The  muscular  contractions  produced  by  the  galvanic  current  are 
diminished  for  about  ten  days.  Subsequently  the  excitability  of  the 
muscles  to  slowly  interrupted  galvanic  currents  becomes  increased,  so  that 
very  weak  currents  may  excite  contractions.  This  may  disappear  in  five 
or  six  months. 

4.  The  polar  reactions  become  altered  in  their  sequence.  The  anode 
contractions  appear  before  those  of  the  cathode,  as  shown  below: — 

1 A.  C.  C.  instead  of  C.  C.  C.  as  in  health. 

2 C.  C.  C.        "  A.  C.  C.     " 

3 C.  O.  C.        "  A.  O.  C.     "         " 

4 A.  O.  C.         "  C.  0.  C.     "          " 

5.  The  character  of  the  muscular  contractions  becomes  altered.  In 
health,  they  are  sharp,  short,  and  sudden.  When  degeneration  occurs, 
they  are  slow  to  appear;  they  are  prolonged  and  continue  even  during 
the  passage  of  the  current;  and,  finally,  they  assume  the  character  of 
"tetanic"  contractions,  irrespective  of  the  strength  of  the  current  em- 
ployed. 

Finally,  in  unilateral  paralysis  the  electrical  reactions  of  the  muscles 
of  the  paralyzed  side  should  be  contrasted  with  those  of  homologous 
muscles  of  the  unaflTected  side.  When  both  sides  are  impaired,  the 
standard  of  comparison  should  be  that  of  a  healthy  subject  of  about  the 
same  size,  weight,  and  muscular  development. 

Now  let  us  suppose  that  we  suspect  disease  in,  and  wish  to  test  the 
reaction  of  some  special  nerve, — the  musculo-spiral,  for  example.     We 


190  LECTURES   ON   NERVOUS   DISEASES. 

place  the  positive  pole  (An)  of  a  galvanic  battery  over  the  breast-bone 
with  a  large  Hat  electrode  attached,  and  the  negative  pole  (Ka)  over  the 
nerve  (where  it  winds  around  the  humerus  below  the  deltoid  muscle)  with 
an  "interrupting"  small  electrode  attached  to  the  negative  rheophore. 
AVe  then  put  into  circuit  a  few  cells  at  a  time  and  press  the  button  of  the 
interrupting  electrode  at  intervals  till  we  get  a  contraction  of  muscles. 
When  the  current  is  sufficiently  strong  to  excite  the  nerve-trunk,  con- 
traction of  the  extensor  muscles  of  the  forearm  becomes  apparent  (the 
cathodal  closure  contraction).  Thus  we  ascertain  the  number  of  cells  of 
the  battery  in  use,  or  preferably  the  number  of  milliamperes  required  to 
produce  C.  C.  C.  (Ka  S.  Z.  of  the  Germans).  Now  add  a  few  more  cells, 
and  reverse  the  poles  by  means  of  the  commutator.  When  the  circuit  is 
br'oken,  by  releasing  the  button  of  the  interrupting  electrode,  we  get  the 
anodal  opening  contraction  (A.  0.  C,  or  An  0.  Z.),  and,  with  a  few  more 
cells,  the  anodal  closure  contraction  (A,  C.  C,  or  An  S.  Z).  Again  re- 
verse the  current,  and  add  a  few  more  cells.  Now,  on  pressing  the  button 
of  the  interrupting  electrode,  we  get  a  very  intense  cathodal  closure  con- 
traction (C".  C".  C'".,  or  Ka  S.  Z'".),  and,  on  releasing  it,  the  cathodal 
opening  contraction  (C.  O.  C.,or  Ka  O.  Z.)  is  developed,  thus  completing 
the  chain  of  polar  nerve  reactions. 

You  should  bear  in  mind  that  the  polar  nerve-reactions  differ  in  their 
vormal  sequence  from  those  of  the  muscles  when  the  electrode  is  placed 
over  the  "  motor  point "  of  the  muscle  tested. 

NORMAL    NERVE-REACTION. 

C.  C.  C.>A.  O.  C.>A.  C.  C.>C.  0.  C. 

NORMAL    MUSCLE-REACTION. 

C.  C.  C.>A.  C.  C.>A.  0.  C.>C.  0.  C. 

The  final  contraction  (C  O.  C.)  of  each  of  these  series  is  seldom  seen, 
because  the  current  required  to  produce  it  is  too  painful  to  be  endured. 
Feioer  cells  are  required  to  cause  muscular  formulae  than  those  of  a 
nerve-trunk. 

In  recording  the  results  of  an  electrical  examination  of  nerve-trunks 
and  muscles  it  is  best  to  arrange  the  record-page  so  that  the  two  sides 
of  the  bod>'  may  be  easily  contrasted.  The  number  of  galvanic  cells  em- 
ployed or  the  number  of  milliamperes  of  current  (as  shown  b}-  a  galva- 
nometer) should  also  be  specified,  and  the  faradaic  reaction  of  homologous 
nerves  or  muscles  should  be  stated  for  the  purpose  of  comparison  and  for 
clinical  deduction.  We  may  follow  with  advantage  some  such  plan  as  the 
folio  win  or : — 


THE   PRINCIPLES   OF   ELECTRO-DIAGNOSIS. 

Name Date Age 

History  of  Case.     See  page  ....  of  Case-Book. 


191 


FARADAIC    TESTS. 


Nerve  reactions 

Right  side. 

Left  side. 

Extent  of  secondary 
coil  employed.   (In 
centimetres.) 

Nerve  tested. 

1 

Muscle  tested. 

GALVANIC   TESTS. 


Right  side. 

Contraction  pro- 
duced. 

Left  side. 

Nerve  or  muscle 
tested. 

Cells  or  miliam- 
peres. 

Cells  or  milliam- 
peres. 

r 

Nerve-reactions -I 

C.  C.  C. 
A.  O.  C. 
A.  C.  C 
C.  O.  C. 

s-         nerve. 

C.  C.  C. 
A.  C.  C. 
A.  O.  C. 
C.  O.  C. 

>      muscle. 

Slips  of  this  character  may  be  printed  and  kept  on  hand.  They  cam 
be  pasted  into  the  case-book  of  the  physician  when  filled  out.  The  tests. 
made  at  different  dates  can  thus  be  compared  with  each  other  and  the 
progress  of  each  case  determined. 


Fig.  59. — The  Author's  Spring  Electrode. — V,  the  binding-post  for  attaching  the  rheophore 
which  connects  it  with  the  battery,  or  with  the  diagnostic  key-board  when  that  instrument  is 
employed.  The  motor  point  of  the  electrode  is  represented  as  enveloped  in  chamois-skin. 
It  must  betharoughly  dampened  in  salt-and-water  before  it  is  applied  to  the  nerve  or  muscle 
to  be  tested.  The  other  end  of  the  electrode  is  designed  to  prevent  slipping  of  the  instru- 
ment after  its  proper  adjustment. 

For  the  purpose  of  demonstrating  the  special  action  of  individual 
muscles  and  nerves  before  classes  of  students,  as  well  as  the  study  of 
muscle-  and  nerve-reactions  in  disease,  I  have  devised  small  electrodes 
which  may  be  made  stationary  upon  any  desired  part  of  the  head,  limbs, 
or  trunk,  by  means  of  straps,  strips  of  adhesive-plaster,  or  insulated 
springs.  By  means  of  these  I  have  been  enabled  to  make  many  points 
clear  to  a  large  audience  which  would  be  extremely  difficult  to  show  by  any 


192  LECTURES   ON  NERVOUS  DISEASES. 

other  method.  Furthermore,  it  is  often  desirable  to  refer  from  time  to 
time  durinir  an  examination  of  a  patient  to  the  effects  of  currents  of  known 
intensity  upon  certain  nerves  and  muscles  for  the  sake  of  accurate 
comparison ,  etc.  Small  electrodes  of  the  type  described  may  be  accurately 
placed  upon  a  patient  and  allowed  to  remain  upon  the  spot  selected  durin^j 
the  entire  examination.  To  each  of  these  a  separate  rheophore  may  be 
attached,  and,  by  a  simple  device  of  my  own,  each  may  be  controlled  by 
touching  a  key  upon  a  board,  without  movement  of  the  operator.  I  can 
thus  observe  simultaneously  the  reactions  of  corresponding  muscles  or 
nerves  upon  the  two  sides,  those  of  the  leg  and  arm  of  the  same  side,  and 
any  other  comparisons  which  may  be  required  in  diagnosis.  The  "  motor- 
points  "  of  the  body  are  not  alwaj's  exactly  where  charts  depict  them ; 
hence  it  is  sometimes  necessary  to  hunt  for  them  within  a  radius  of  an 
inch  or  two  of  the  normal  point.  When  the}^  are  found  with  exactness, 
a  small  electrode  may  be  fastened  over  the  spot  (with  moistened  ab- 
sorbent cotton  beneath  it)  and  allowed  to  remain  stationary  during  the 


Fig.  60. — The  Author's  Diagnostic  Key-board. — A,  the  rheophore  which  connects  it  with 
one  of  the  binding-posts  of  a  galvanic  battery  ;  B,  rheophores  connecting  its  binding-posts 
with  spring  electrodes  previously  placed  upon  the  body  of  the  patient  so  as  to  influence  the 
nerves  or  muscles  to  be  tested;  C,  buttons  and  springs  which  make  a  circuit  to  the  body  of 
the  patient  when  the  knob  on  the  spring  is  pressed  downward  so  as  to  impinge  upon  the 
button.  The  number  of  rheophores  which  may  be  employed  depends  upon  the  necessities 
of  the  case ;  the  cut  shows  an  instrument  capable  of  six. 

entire  sitting.  Whenever  it  becomes  necessary  to  refer  to  the  reactions 
of  that  point,  it  can  be  called  into  action  by  touching  the  key  connected 
with  it  by  its  individual  rheophore.  The  cuts  introduced  show  the  ar- 
rangement of  my  device  for  this  purpose.  I  have  given  a  more  com- 
plete description  of  the  advantages  of  this  method  over  others  previousl}' 
emploj^ed,  in  the  Neiv  York  Medical  Journal  of  May  9.  1885. 

Now,  from  such  a  table  of  record  it  is  apparent  that  the  faradaic 
current  i^hould  first  be  employed  upon  the  patient  (the  poles  of  the  sec- 
ondary coil  being  used).  The  extent  of  the  overlaj)  of  this  coil  (in  centi- 
metres) necessary  to  produce  muscular  contractions  when  the  nerve-  and 
muscle-reactions  are  being  separately  tested  should  be  recorded.  In  case 
no  muscular  contractions  ensue,  the  extent  of  the  overlap  which  produces 


THE   PEINCIPLES    OF   ELECTRO-DIAGNOSIS. 


193 


an  unbearably  jjainfid  current  should  be  ascertained  and  noted.  This 
may  be  compared  with  tliat  necessary  to  produce  contractions  upon  the 
healtiiy  side. 

The  next  step  in  the  examination  consists  in  changing  the  rheophores 
to  the  binding-posts  of  a  galvanic  battery.  We  can  now  ascertain  the 
number  of  cells  or  milliamperes  (which  is  preferable)  required  to  produce 
the  different  varieties  of  contractions  (enumerated  in  the  table  designed 
for  record)  of  muscles  in  homologous  regions  of  the  right  and  left  sides. 
Each  nerve  which  is  impaired  should  be  tested  first;  and  the  muscles 


Fig.  61. — The  Author's  Diagnostic  Key-board  as  Applied  in  Actual  Use. — The  spring 
electrodes  are  represented  in  the  cut  (for  the  purpose  of  illustration)  as  applied  to  the  facial, 
ulnar,  and  musculo-spiral  nerves  of  each  side.  If  he  so  chooses,  the  operator  can  have  his 
case-book  on  a  stand  at  his  right,  for  recording  his  observations  as  they  are  made. 

supplied  by  it  should  be  tested  afterward.  The  strength  of  the  current 
employed  should  be  ascertained  by  throwing  a  galvanometer  into  the 
circuit  (when  extreme  accuracy  is  desired);  by  so  doing,  a  comparison 
of  the  nerve-  and  muscle-reactions  of  the  two  sides  can  be  based  upon 
conditions  which  are  exactly  alike. 

When  we  have  completed  the  steps  indicated  by  the  chnrt  prepared 
for  the  assistance  of  the  practitioner  (page  191)  we  are  in  ])ossession  of 
certain  facts  which  may  be  of  great  practical  value  as  regards  both  diag- 
nosis and  prognosis: — 

13 


194  LECTURES    ON    NERVOUS   DISEASES. 

1.  Suppose  a  case  of  localized  paralysis  is  examined,  and  the  fara- 
daic  and  galvanic  reactions  of  both  a  nerve  and  its  muscles  are  normal 
and  exactly  alike  on  the  two  sides.  We  have  reason  then  to  believe  that 
the  exciting  cause  is  either  hysteria,  a  lesion  of  a  higher  spinal  segment 
than  that  from  which  the  nerve  arises,  or  a  lesion  within  the  brain,  pro- 
vided the  possibility  of  deception  on  the  part  of  the  patient  respecting 
his  paralytic  condition  can  be  excluded. 

2.  If  the  nerve-7'eactions  of  the  affected  side  to  both  currents  are 
exaggerated  (i.e.,  if  the  contractions  occur  in  their  proper  sequence,  but 
under  a  weaker  current  than  in  health),  the  jyrobabilitg  of  an  existing  cen- 
tral lesion  is  heightened,  although  hysteria  may  j^ossibly  still  exist  as  the 
exciting  cause  of  the  paralysis. 

3.  If  the  faradaic  current  applied  through  tlie  nerve  fails  to  pro- 
duce contractions  of  the  affected  muscles  as  readily  as  upon  the  healthy 
side  (i.e.,  if  a  stronger  current  is  demanded  to  call  any  one  of  the  para- 
lyzed muscles  into  action  indirectly  through  the  nerve  which  supplies  it,) 
then  we  know  that  the  verve  f  laments  within  the  spinal  cord  or  those  of 
the  trunk  of  the  nerve  itself  are  affected  by  a  lesion  which  has  impaired 
but  not  entirely  destroyed  their  usefulness. 

4.  If  r?o  current  from  a  ftiradaic  machine  (which  can  be  endured  by 
the  patient)  causes  muscular  contractions,  we  know  positively  tliat  the 
motor  cells  of  the  anterior  horns  of  that  spinal  segment  which  controls 
the  paralyzed  muscles  are  impaired,  or  that  the  nerve  itself  has  been  sev- 
ered from  its  connection  with  the  spinal  cord,  or  is  undergoing  degen- 
eration. 

5.  When  the  muscle-reactions  to  the  faradaic  current  have  been 
tested,  the  previous  deductions  (based  on  tlie  nerve  reactions)  still  hold 
good.  The  electrode  should,  however, be  placed  over  the  "motor  point" 
of  each  muscle  thus  tested.  These  are  shown  in  plates  at  the  end  of  this 
volume. 

6.  If  the  formidse  obtained  by  the  galvanic  current  are  normal,  all 
questions  regarding  the  existence  of  degenerative  changes  in  the  nerve- 
or  the  muscle-plates  can  be  excluded.  When  the  no7'mal  order  is  altered, 
degenerative  changes  in  the  nerve-  or  the  motor-cells  of  the  spinal  cord 
are  present. 

1.  The  history  of  a  case  in  which  motility  is  impaired  is  never 
complete  without  a  record  of  an  electrical  examination  of  the  nerve-  and 
muscle-reactions  to  both  the  faradaic  and  galvanic  current.  When  doubt 
exists  respecting  the  existence  of  a  cerebral  lesion  or  hysteria,  the  facts 
obtained  by  otlier  methods  of  examination  (fully  described  by  me  in  the 
preceding  pages)  will  clear  up  all  doubts. 

8.  Patients  afflicted  with  paralysis  from  a  cerebral  lesion  generally 
exhibit  normal  electro-nerve  and  electro-muscular  reactions  in  the  para- 
lyzed parts.     In  some  instances  the  reactions  may  even  be  exaggerated. 


DETECTION    OF   FEIGNED   DISEASES.  195 

9.  Hijsterical  patients  afflicted  with  paralysis  may  exhibit  either 
normal  or  exaggerated  electro-muscular  reactions  to  faradism  or  gal- 
vanism. The  sensitiveness  of  the  muscles  to  faradism  is  generally  de- 
creased ;  in  some  cases  it  may  be  totally  wanting  (Duchenne). 

10.  In  rheumatic  par-alysis  the  electro-muscular  contractility  is,  as 
a  rule,  markedly  increased;  this  may  be  shown  by  a  comparison  of  the 
reactions  of  the  two  sides  of  the  bod3\  In  exceptional  cases  this  is  not 
found  to  be  so,  as  I  have  seen  the  reactions  follow  only  the  strongest 
currents. 

11.  In  perij)heral  paralysis  the  faradaic  and  galvanic  reactions  are 
altered  after  ten  days  have  elapsed.  The  muscular  contractility  to  the 
faradaic  current  is  lost  early  to  a  greater  or  less  extent ;  and  the  formula 
of  degenerative  changes  is  developed  later  by  the  emploj'ment  of  the 
galvanic  current. 

12.  A  decreased  musculo-excitability  to  the  faradaic  current  in  the 
musculo-spiral  nerve  and  the  extensor  muscles  of  the  forearm  on  both 
sides — the  flexors  being  normal  and  the  lower  extremities  being  unaffected 
— tells  us  of  the  approach  of  lead-poisoning  before  the  actual  symptoms 
are  well  marked. 

13.  In  progressive  muscular  atrophy  a  response  to  the  faradaic 
current  can  be  obtained  as  long  as  any  fibres  in  the  muscle  tested  remain 
free  from  fatty  metamorphosis. 

14.  No  alterations  in  the  electro-contractility  of  muscles  is  observed 
in  any  of  the  diseases  confined  to  the  posterior  part  of  the  sp)inal  cord. 

DETECTION   OF  FEIGNED  DISEASES. 

In  addition  to  the  uses  of  electricity  for  the  purpose  of  determining 
the  presence  or  absence  of  nerve-  and  muscle-degeneration,  and  the  dis- 
crimination between  cerebral  and  spinal  paralysis  and  the  various  t3"pes 
of  pei'ipheral  palsies,  some  other  useful  purposes  in  diagnosis  have  been 
published  from  time  to  time. 

It  is  stated  that  muscular  contractions  produced  by  the  faradaic 
current  cannot  be  maintained  over  four  hours  in  a  dead  subject. 

Malingerers  are  not  uncommon  among  the  applicants  for  charitable 
aid,  and  they  are  occasionalh^  encountered  among  the  higher  walks  of 
life.  Epilepsy  and  paralysis  are  the  most  common  diseases  which  are 
feigned. 

Feigned  epileptsy  can  be  distinguished  by  the  application  of  a  strong 
faradaic  current  to  the  forehead  or  tibia  by  means  of  a  wire  brush.  The 
intense  pain  so  produced  will  not  be  appreciated  by  a  true  epileptic,  but 
will  bring  the  fit  to  a  sudden  close,  if  assumed  in  order  to  create  s^'m- 
pathy  or  aid. 

Feigned  motor  paralysis  is  usually  exhibited  in  some  of  the  vari- 


196  LECTUEES   ON  NERVOUS   DISEASES. 

ous  forms  of  peripheral  paralysis.  Few  malingerers  know  enough  to 
simulate  hemiplegia  or  paraplegia  without  detection.  If  two  weeks  have 
elapsed  since  the  attack,  the  presence  of  normal  electrical  reactions  of 
nerve  and  muscle  in  the  affected  limb  is  strong  ground  for  suspicion, 
provided  a  histor}'  of  some  cerebral  lesion  or  of  hysteria  cannot  be 
elicited.  There  are  various  other  tests  which  a  skilled  anatomist  can 
emploj''  in  each  case  that  will  help  to  clear  up  all  doubts  upon  this 
subject. 

Feigned  anaesthesia  may  be  told  b}-  the  use  of  the  faradaic  current 
with  the  wire  brush  attached  to  the  negative  rheophore.  The  opposed 
limbs  will  quickly  show  how  much  actual  anaesthesia  exists. 

DETECTION   OF   BULLETS   OE   BUEIED   METAL. 

An  ingenious  application  of  electricity'  to  surgery-  has  been  made 
which  has  utility  in  diagnosis. 

The  so-called  '■'■  electric  probe''''  consists  of  two  wires  which  are  per- 
fectl}'  insulated  from  each  other  by  rubber  or  ivor}'.  These  wires  ter- 
minate in  metal  tips  which  project  slighth'  beyond  the  insulating  medium, 
and  at  the  other  end  of  the  wires  a  galvanic  cell  and  an  electro-magnet 
acting  upon  a  bell  are  attached.  When  the  probe  is  pushed  into  the 
tract  made  by  a  metallic  missile,  and  the  tips  are  brought  into  contact 
with  it,  the  circuit  is  completed  and  the  bell  rings.  The  animal  tissues 
are  not  sufficiently  good  conductors  of  electricity  to  form  a  circuit; 
hence  the  bell  will  not  ring  until  the  metal  is  touched  by  the  tips  of  the 
probe. 

Recent  experimentation  with  the  so-called  "  induction  balance  "  goes 
to  prove  this  instrument  of  great  value  in  some  cases  where  buried  metal 
is  suspected  to  exist  beyond  the  reach  of  a  probe. 

ELECTEO-DIAGNOSIS   OF   AUEAL   DISEASES. 

"We  owe  to  Brenner,  of  St.  Petersburg,  the  first  suggestion  of  this 
use  for  electric  currents  in  diagnosis.  From  a  somewhat  limited  expe- 
rience in  its  use,  I  am  led  to  believe  that  its  utility  cannot  longer  be  called 
into  question.  Brenner's  formula  seems,  furthermore,  to  be  in  accord 
with  all  that  has  l)een  proved  in  respect  to  nerve-trunks  in  health,  in  all 
parts  of  the  body.  The  formula  is  simply  that  of  the  galvanic  reaction 
of  the  auditory  nerve  in  health. 

1.  In  place  of  the  C.  C.  C.  observed  in  muscle,  we  get,  when  a  gal- 
vanic current  is  sent  through  the  auditory  nerve,  a  ringing  noise  when 
the  cathodal  closure  occurs.     (C.  C.  S.) 

2.  The  cathodal  opening  produces  no  effect. 

3.  The  anodal  opening  produces  a  ringing  noise  when  a  current  of 
high  intensity  is  employed. 


ELECTRICAL  TESTS  OF  THE  SPECIAL  SENSES.       197 

4.  After  the  cathodal  closure  {cathodal  duration — C.  D.),  the  ring- 
ing noise  produced  at  the  closure  gradiiaUy  diminishes. 

The  formula  which  is  indicative  of  health  when  a  pole  is  connected 
with  each  ear  may  be  expressed  in  symbols,  as  follows: — 

Right  Ear  (AnoJe).     Left  Ear  (Cathode). 

C.  (closure)    S.  (loud) 

O.  (opening) S.  (weak)  

D.  (duration) S.  > 

Now,  it  is  maintained  by  Brenner  that  any  deviation  from  the  normal 
reactions  of  the  auditory  nerve  (shown  in  the  preceding  formula)  indicates 
disease  of  the  acoustic  mechanism.  The  variations  produced  by  the  dif- 
ferent diseased  conditions  encountered  cannot  be  given  here  from  want 
of  space. 

In  applying  galvanic  currents  to  the  ear,  it  is  best  to  place  a  medium- 
sized  electrode  over  the  entire  tragus  or  to  fill  the  external  auditory  canal 
of  the  ear  to  be  tested  with  tepid  water  containing  a  little  salt,  and  then 
to  introduce  an  electrode  of  metal  inclosed  in  an  aural  speculum  of  hard 
rub])er  into  the  ear  until  the  metal  touches  the  water.  If  each  ear  is  to 
be  tested  separately,  the  other  electrode  should  be  placed  at  an  indif- 
ferent point,  preferably  the  mastoid  region  of  the  same  side  or  the  middle 
of  the  sternum. 

Regarding  this  test,  it  is  well  to  state  that  repeated  sittings  are  often 
necessary.  The  patient  has  to  become  accustomed  to  the  disagreeable 
effects  of  the  current.  It  is  desirable  that  you  begin  with  very  weak 
currents  and  increase  the  strength  very  gradually.  As  the  reaction  of 
cathodal  closure  (C.  C.)  is  the  most  important,  it  can  be  intensified  by 
previously  allowing  cathodal  duration  (C.  D.)  to  act,  or  by  rapidly  fol- 
ing  C.  C.  by  A.  0. 

EXAMINATION   OF  THE   EYE,    NOSE,    AND   MOUTH  BY   ELECTRICITY. 

Special  effects  are  produced  upon  the  organs  of  sight,  smell,  and 
taste  by  electric  currents.  Sparks  or  vivid  flashes  of  light  follow  electric 
stimulation  of  the  eye;  and  subjective  odors  and  tastes  are  also  produced 
when  the  olfactory  and  gustatory  nerves  are  excited  by  this  agent.  The 
"  polar  method  "  of  examination  is  emploj^ed  when  any  of  the  special 
senses  are  thus  tested.  I  would  caution  the  I'eader  against  employing 
too  strong  currents  about  any  of  the  organs  of  special  sense.  The  ex- 
amination of  the  optic,  olfactory,  and  gustatory  nerves  requires  expe- 
rience and  should  not  be  attempted  by  novices. 

When  examining  the  7'eactions  of  the  eye,  the  small  electrode  is 
placed  upon  the  closed  ej^elid,  temple  or  forehead.  The  large  electrode 
is  placed  upon  the  back  of  the  neck.  The  room  should  be  darkened  and 
the  patient  should  keep  both  eyes  closed. 


198 


LECTURES   ON   NERVOUS   DISEASES. 


"When  fe.Hfing  the  sense  of  faste,  the  poles  should  lie  in  contact  with 
the  cheeks,  and  the  sensations  of  taste  exi)erienced  upon  both  sides  by 
the  patient  should  be  ascertained.  A  fine  electrode  can  also  be  placed 
upon  the  tongue,  the  pharynx,  or  the  inside  of  the  cheek,  in  case  local- 
ized polar  reactions  are  to  be  determined.  A  double  electrode,  with  two 
metal  tips  which  are  not  in  contact,  ma^'  be  employed  for  this  purpose 
(Neumann). 

ELECTRICAL  EXAMINATION    OF   THE   SENSIBILITY   OF  THE   SKIN. 

The  electrode  devised  by  Erb  is,  to  my  mind,  the  best  for  this  pur- 
pose. It  consists  of  four  hundred  varnished  wires  in  a  tube  of  hard 
rubber.  The  ends  of  these  wires  make  a  perfectly  smooth  surface.  This 
electrode  is  connected  with  the  secondary  coil  of  a  faradaic  machine  and 


Fig.  62. — Erb's  Electrode  for  the  Examination  of  Far.\do-Cutaneous  Sensibility. — 
a,  A  hard-rubber  tube  ;  i>,  the  free  surface  of  the  electrode. 

is  then  pressed  upon  the  area  of  the  body  to  be  tested — the  other  pole 
being  at  the  sternum.  Tlie  minimum  of  the  overlap  of  the  secondary 
coil  which  can  be  felt,  and  the  maximum  which  can  be  endured,  are  both 
recorded.  Homologous  parts  of  each  side  should  be  compared  with  each 
other. 

Regarding  this  test  Erb  wisely  remarks:  "The  skin,  regarded  as  a 
sensory  organ,  cannot  be  tested  with  irritants  other  than  those  adequate 
to  it, — viz.,  touch,  pressure,  various  temperatures,  and  the  higher  grades 
of  those  irritants  which  produce  pain.  It  may  be  disputed  whether  elec- 
tricity should  be  included  among  these  'adequate'  irritants  of  the  skin. 
The  electric  sensation  is  a  specific,  distinct  quality  of  tegumentary  sen- 
sibility, whose  careful  examination,  however,  is  of  value  in  many  morbid 
conditions." 


TESTS   OF  THE   SENSOEY  NERVES.  199 

TESTS   TO   DETERMINE    THE    CONDITION    OF    THE    SENSOEY   NEEVES. 

Before  completing  a  diagnosis  of  some  forms  of  nervous  disease,  it 
is  necessary  to  investigate  the  following  functions:  1,  The  condition  of 
the  sensory  nerves  of  the  skin  in  respect  to  the  sense  of  touch;  2,  the 
appreciation  by  these  nerves  of  varying  degrees  of  temperature;  3,  the 
appreciation  by  the  patient  of  painful  impressions  transmitted  to  the 
brain  by  the  nerves;  and  4,  the  condition  of  the  special  senses  of  sight, 
smell,  hearing,  and  taste. 

TESTS   FOE   TACTILE   SENSIBILITY. 

In  this  series  of  tests,  as  also  in  those  employed  to  detect  abnor- 
malities of  appreciation  of  different  degrees  of  temperature,  the  following 
precautions  must  be  taken  against  error  in  the  results  obtained : — 

1.  The  nature  of  the  tests  to  be  employed  must  be  clearly  explained 
to  the  patient,  as  well  as  the  importance  of  accuracy  in  his  decision  re- 
specting the  sensations  perceived.  This  insures  his  intelligent  coopera- 
tion, and  makes  the  patient  more  earnest  in  his  endeavors  to  answer 
correctl3\ 


Fig.  63. — Beard's  Piesmeter. — This  instrument  consists  of  a  spring  in  a  tube  that  resists  press- 
ure made  upon  the  piston.  A  scale  indicates  the  amount  of  pressure  uiion  the  spring.  It 
is  employed  to  determine  the  degree  of  sensitiveness  to  pressure  in  different  parts  of  the 
body  The  forehead,  tongue,  and  cheek  are  the  most  sensitive  to  pressure;  the  least  so  are 
the  backs  of  the  thighs  and  legs. 

2.  It  is  preferable  that  the  patient  he  blindfolded,  in  order  to  avoid 
any  information  respecting  the  tests  used  reaching  him  by  sight. 

3.  To  malce  the  patient  keenly  alert  to  avoid  errors  of  statement,  it 
is  well  to  employ  blank  experiments  from  time  to  time.  Thus,  when  the 
skin  has  not  been  touched  with  any  instrument  or  foreign  substance,  it 
is  well  to  ask  "where  the  object  is  now  felt,"  "how  many  points  are  now 
in  contact  with  the  skin,"  etc. 

Having  explained  the  objects  of  the  tests  about  to  be  employed  and 
then  blindfolded  the  patient,  the  tactile  sensibility  of  the  skin  should  be 
first  determined  by  the  following  methods  : — 

(1)  Consciousness  of  simple  contact  impressions.  When  the  skin 
is  brushed  by  a  hair  or  a  fine  feather,  notice,  first,  if  the  patient  perceives 
the  contact  immediately,  and,  secondl}',  if  he  can  describe  the  sensation 
correctly. 

(2)  The  ability  to  locate  contact  impressions.  With  tests  of  de- 
creasing delicacy  (the  touch  of  a  hair  being  the  most  delicate,  and  painful 
impressions  the  least  so),  notice  to  what  extent  the  patient  is  able  to 


200 


LECTURES   ON   NERVOUS   DISEASES. 


correctly  designate  the  point  of  contact  of  the  body  employed  with  the 
skin  of  different  h:)Ciiiities. 

(3)  The  degree  of  sensibility  of  dif/'erent  regions.  This  has  to  be 
investigated  with  great  care  in  some  cases.  Several  methods  are  em- 
ployed to  determine  it  with  accuracy.     Those  are  as  follows: — 

(a)  Objects  of  diferent  shapes  may  be  laid  upon  the  skin  and  the 
patient  requested  to  describe  their  form  and  character.  Coiiis,  keys,  and 
w^eights  may  be  emi)loyed  for  this  purpose,  as  they  are  always  to  be  had. 
This  test  should  be  used  over  many  parts  of  the  body,  and  the  results 
obtained  compared  with  those  of  similar  experiments  made  by  the  phy- 
sician upon  himself  or  some  healthy  person. 


pi  b^i.ii-iin?rn-| 


Fig.  64. — Hammond's  yEsTHESiOMETER. — When  closed  it  can  be  conveniently  carried  in  the  pocket. 


(b)  The  appreciation  of  pressure,  as  suggested  by  Weber,  may  be 
tested  by  placing  weights  of  varying  sizes  upon  the  skin  of  some  part, 
that  has  previously  been  supported  in  order  to  avoid  the  so-called  "mus- 
cular sense"  being  a  factor  in  the  patient's  decision.  Dr.  Beard  has  de- 
vised an  instrument  for  this  test  that  answers  all  purposes  very  well. 

(c)  Again,  the  various  forms  of  festhesiometers  are  used  to  detect 
the  minimum  distance  which  can  exist  between  two  points  of  simple 
contact  with  the  skin  without  destroying  the  distinct  percejjtion  of  both 
points  by  the  patient.  This  distance  varies  in  health  between  extremely 
wide  limits,  because  some  regions  are  abundantly  supplied  with  sensory 


TESTS   FOR  TACTILE   SENSIBILITY. 


201 


nerves  and  tactile  corpuscles,  while  others  are  not.  For  this  reason,  the 
following  measures*  can  be  used  as  the  healthy  standard  for  comparison 
in  any  given  case.  They  are  given  in  inches,  lines,  and  millimetres  so 
as  to  meet  the  requirements  of  any  scale : — 

1.  Point  of  tongue ^^^  inch 

2.  Palmar  surface  of  finger  tips    .  yV  " 

3.  Mucous  surface  of  Ups  ....  ^  " 

4.  Palm  of  hand  and  tip  of  nose  .  J  " 

5.  White  part  of  lips J  " 

6.  Lower  part  of  forehead     ...  f  " 

7.  Back  of  hand H  " 

8.  Dorsum  of  foot IJ  '' 

9.  Forearm 1|  " 

10.  Sternum If    " 

11.  Middle  of  thigh 2.^  inches  =  30 

12.  Back 21 


=    i  line 

=    1.1  ra 

=    1    " 

•)  2     " 

=    2  lines 

=    4.2     " 

=    3     " 

=    6.3     " 

=    4     " 

=    8.4     " 

=  10     " 

=  21.1     " 

=  14     " 

=  29.2    '• 

=  18     " 

=  37.5     " 

=  19     " 

=  39.6     " 

=  21     " 

=  44.1     " 

=  30    " 

=  62.5    " 

=  31     " 

=  66.0    " 

Fig.  65.— Carroll's  .(Esthesiometer  —The  instrument  has  two  points  upon  each  leg  of  the 
compass,  one  blunt  and  the  other  sharp.  It  is  a  convenient  instrument  to  determine  the  con- 
dition of  the  sensory  nerves  in  respect  to  contact  sensations  and  those  of  pain.  1  his  is  ac- 
complished by  simply  substituting  the  blunt  for  the  sharp  points,  or  vice  versa. 

Various  forms  of  Ksthesiometers  have  been  devised,  but  a  simple 
pair  of  compasses,  such  as  are  used  by  artists,  will  answer  all  purposes. 


kii;iiiiillliM>**     ^^ 

Fig.  66. — Sieveking's  .^sthesiometer. — A  modification  of  the  ordinary  beam  compass  em- 
ployed oy  carpenters,  but  graded  in  inches  and  tenths  of  an  inch.    Its  points  are  not  sharp. 

The  distance  between  the  points  can  be  ascertained  by  a  rule  graded  in 
inches,  lines,  or  millimetres.  The  points  should  not  be  sharp^  as  they  will 
cause  pain  if  so,  and  thus  defeat  the  object  of  this  test. 

*  More  complete  tables  than  the  one  offered  may  be  found  in  many  of  the  later  works 
on  physiology  and  nervous  diseases. 


202  LECTURES   ON  NERVOUS   DISEASES. 

The  suggestions  previously  made  respecting  the  definite  instructions 
to  the  patient,  the  use  of  blank  experiments,  and  the  employment  of  a 
bandage  over  the  patient's  eyes,  apply  to  this  test  as  well  as  to  those  pre- 
viously- described. 

The  following  rules  must  be  observed  in  case  the  aesthesiometer  is 
to  be  used  : — 

1.  The  two  points  of  the  instrument  must  be  made  to  touch  the  skin 
simultaneously;  otherwise  the  patient  will  detect  the  two  points  of  con- 
tact more  readil}-  than  if  both  meet  the  skin  at  the  same  moment. 

2.  The  contact  should  be  a  gentle  one;  otherwise  the  impression 
upon  the  skin  becomes  a  painful  sensation. 

3.  The  relative  position  of  the  two  points  should  always  bear  the 
same  relation  to  the  axis  of  the  limb  or  median  line  of  the  body,  because 
the  sensibility  of  a  part  is  affected  differently  when  the  points  are  directed 
transversely  or  longitudinally'.  This  is  essential  to  the  accurate  com- 
parison of  the  sensibilit}'  of  difl'erent  regions  of  the  body,  or  of  corre- 
sponding regions  of  either  side. 

4.  The  taljle  which  has  been  previously  given  should  be  employed 
as  a  standard  of  comparison  only  ichen  the  sensory  functions  of  the  skin 
are  impaired  upon  both  sides.  When  the  derangement  is  one-sided,  the 
healthy  side  will  be  the  safest  guide  for  comparison. 

ABNORMAL  CONDITIONS  OF  SENSATION. 

We  are  now  prepared  to  consider  the  significance  of  the  disorders 
of  cutaneous  sensibility,  viz.,  anaesthesia  or  loss  of  sensibility;  hyper- 
sesthesia,  or  increased  sensibility;  the  existence  of  pain;  and  the  lack  of 
appreciation  of  varying  degrees  of  temperature. 

Anaesthesia. — Certain  regions  of  the  body  may  be  deprived  of 
cutaneous  sensibility  (either  totally  or  partiallj^)  (1)  by  diseased  con- 
ditions of  the  brain  or  spinal  cord,  and  (2)  by  any  abnormal  state  of  the 
nerves  themselves  that  tends  to  impair  or  destroy  their  abilit}'  to  conduct 
sensations  to  the  nerve  centres. 

In  the  latter  case,  the  loss  of  sensation  is  liable  to  be  associated 
with  an  impairment  also  of  motion,  because  the  cerebro-spinal  nerves  are 
composed,  as  a  rule,  of  both  motor  and  sensor}-  fibres.  The  fact  that 
sympathetic  nerve  fibres  are  also  present  in  the  majority  of  nerves,  helps 
us  to  explain  certain  disorders  in  the  nutrition  of  tlie  skin  that  some- 
times accompany  motor  or  sensory  paralysis  dependent  on  injury  or  de- 
struction of  some  individual  nerve. 

The  regions  of  the  spinal  cord  and  brain  that  are  functionally  asso- 
ciated with  sensation.,  liave  been  already  touched  upon  in  Section  I.  It 
may  be  stated  in  a  general  way  that  the  nerve  fibres  that  conduct  sensory 
impressions  from  the  peripheral  parts  of  the  body  to  the  brain  travel 


ABNOKMAL  CONDITIONS  OF  SENSATION.  203 

cliiefly  through  the  posterior  columns  of  the  spinal  cord  and  its  gray  matter 
in  order  to  reach  the  brain — the  seat  of  intelligent  perception  of  sucli 
sensations.  Within  the  substance  of  the  brain  itself,  these  fibres  pass 
through  the  outer  part  of  the  formatio  reticularis  and  ih.e  posterior  part 
of  the  so-called  '■'■internal  capsule''''  of  that  organ.  We  are  justified,  I 
think,  in  drawing  the  following  clinical  deductions  as  regards  the  exist- 
ence of  cutaneous  anaesthesia: — 

1.  Lesions  of  the  cerebral  hemispheres  produce  anaesthesia  when 
they  involve  the  posterior  one-third  of  the  internal  capsule. 

If  the  sensory  cranial  nerves  are  affected  by  such  a  lesion,  the  loss 
of  sensation  is  commonly  on  the  same  side  as  the  lesion,  except  in  case 
of  the  optic  nerve  (the  condition  known  as  hemianopsia).  The  anaes- 
thesia of  parts  below  the  head,  if  due  to  cerebral  causes,  is  confined  to 
the  side  opposite  to  the  hemisphere  in  which  the  lesion  exists. 

2.  Anaesthesia  from  lesions  of  one  lateral  half  of  the  substance  of 
the  spinal  cord  exists,  as  a  rule,  on  the  side  opposite  to  the  spinal 
lesion. 

3.  Lesions  which  involve  both  lateral  halves  of  the  spinal  cord 
create  anaesthesia  on  both  sides  of  the  body,  provided  the  destructive 
process  affects  the  so-called  "sensory  tract"  of  the  cord,  viz.,  the  pos- 
terior columns,  or  the  gra}'  matter  around  its  central  canal. 

4.  Anaesthesia  may  exist  on  the  same  side  as  a  spinal  lesion^  pro- 
vided the  posterior  roots  of  the  spinal  nerves  be  pressed  upon  or  de- 
stro^'ed  by  it,  or  in  case  the  sensory  nerves  be  affected  by  the  spinal 
lesion  before  i\iQy  cross  to  the  opposite  side  of  the  cord. 

5.  Anaesthesia,  unlike  motor  paralysis,  is  not  necessarily  present  in 
parts  of  the  body  supplied  by  those  nerves  that  are  given  off  from  the 
cord  below  the  seat  of  the  lesion.  Anaesthesia  is  often  associated  with  a 
condition  of  increased  sensibilit}'  or  "hyperaesthesia"  of  parts  below  the 
seat  of  the  spinal  lesion,  and  on  the  side  opposite  to  it. 

6.  Anaesthesia  may  often  co-exist  with  other  sensory  S3'mptoms, 
such  as  pain,  incoordination  of  movement,  the  peculiar  sensation  known 
as  "formication,"  numbness,  tingling,  and  other  subjective  sensations. 

7.  Anaesthesia  of  spinal  origin  is  generally  bilateral  and  symmet- 
rical^ because  lesions  of  the  cord  commonly  affect  both  lateral  halves. 

8.  Tactile  sensibility  may  be  destroyed  by  spinal  lesions,  and  yet 
the  sensibility  to  pain  and  temperature  may  occasionally  be  retained. 

9.  Unilateral  anaesthesia  of  the  face  and  of  the  opposed  arm  and 
leg  indicates  a  unilateral  lesion  of  the  formatio  reticularis. 

In  rare  cases,  sensibility  to  temperature  may  be  lost,  and  the  sensi- 
bility to  pain  and  touch  may  be  normal.  It  is  not  extremely  infrequent 
for  the  neurologist  to  record  an  absence  of  sensibility  to  pain,  when 
tactile  sensibility  remains  unaffected,  and  accurate  perceptions  of  tern- 


I 


204  LECTURES  ON  NERVOUS  DISEASES. 

perature  are  still  experienced  by  the  patient.  These  suhjccts  can  detect 
a  needle  thrust  into  the  muscles  from  a  simple  sensation  of  touch.  These 
clinical  facts  seem  to  confirm  the  view  tliat  has  been  advanced  by  late 
physiologists,*  viz.,  that  the  patlis  of  conduction  of  sensations  of  touch, 
pain,  and  temperature  probably  lie  in  different  parts  of  the  spinal  cord. 

Hyperesthesia. — The  skin  may  be  rendered  extremely  sensitive  in 
certain  diseased  conditions.  This  abnormal  state  of  the  nerves  is  termed 
"hypertesthesia"  in  contradistinction  to  "  anaesthesia  "  or  a  loss  of  sen- 
sation. 

When  the  "sensory  tracts"  of  the  spinal  cord  are  involved  by  a 
localized  lesion,  the  2io?'ts  beloiv  the  regions  that  are  rendered  anfefithefir 
b}'  the  cutting  of  the  sensory  nerves  are  sometimes  affected  -with  liyper- 
aesthesia.     The  cause  of  this  is  not  3'et  definitely  known. 

A  narrow  band  of  hypereeslhesia.  is  also  developed,  as  a  rule,  at  the 
upper  level  of  the  spinal  lesion.  If  in  the  dorsal  region,  this  zone  of 
hj'pergesthesia  generally  encircles  the  body.  When  in  the  lumbar  region, 
it  is  more  or  less  vertical  over  the  limbs  in  accordance  with  the  particular 
spinal  segment  which  happens  to  be  affected. 

Hyperaesthesia  probably  indicates,  according  to  our  present  knowl- 
edge, some  irritation  of  the  nerve  fibres  distributed  to  the  regions  so 
affected.  The  cut  introduced  is  admirably  adapted  to  illustrate  the 
effects  of  a  one-sided  spinal  lesion  upon  the  sensory  functions  of  the  skin. 

In  the  disease  known  as  locomotor  ataxia,  after  a  paroxj'sm  of 
"stabbing  pains"  has  subsided,  the  seat  of  previous  pain  becomes 
markedly  sensitive  to  the  touch,  while  the  rest  of  the  bod^*  is  not  simi- 
larly affected. 

Hyperesthesia  may  be  of  service  in  diagnosis.  It  may  afford  valu- 
able information  respecting  the  spinal  segments  that  are  irritated  by  some 
destructive  process  within  adjacent  regions  of  the  spinal  cord.     Again, 

*The  lateral  columns  (Fig.  .34)  and  the  posterior  columns  are  probably  concerned 
(as  well  as  the  gray  substance  of  the  cord  in  the  region  of  its  central  canal)  in  the  trans- 
mission of  sensory  impressions  to  the  brain. 

Woroschiloff,  Ludwig,  and  Ott  have  apparently  demonstrated  by  careful  and  appar- 
ently conclusive  experiments  that,  in  the  lower  animals,  the  lateral  columns  in  the  dorsal 
region  of  the  spinal  cord  are  physiologically  associated  with  the  transmission  of  sensations 
from  the  legs.  Whether  this  is  true  of  man  is  not  yet  determined,  although  Gower's  re- 
ported case  of  a  crushed  cord  in  man  gave  evidence  of  ascending  degeneration,  both  in 
the  postero-internal  columns  (Goll's  columns)  and  also  in  the  lateral  columns  in  front  of 
the  "  crossed  pyramidal  tract"  (Fig.  29).     Unfortunately,  this  case  stands  alone  as  yet. 

This  view  is  directly  opposed  to  the  older  one  that  has  been  generally  accepted  by 
standard  authors,  viz.,  that  sensations  of  pain  travel  along  the  gray  matter  of  the  cord, 
and  those  of  touch,  and  perhaps  of  temperature,  pass  up  the  posterior  columns  of  the 
spinal  cord. 

The  late  researches  of  Starr  seem  to  prove  that  impressions  of  vmscnlar  aenne  from 
the  upper  limbs  are  transmitted  by  Burdach's  column,  and  from  the  lower  limbs  by  Goll's 
column  of  the  corresponding  side  of  the  cord. 


ABNORMAL  CONDITIONS  OF  SENSATION. 


205 


if  limited  to  tlie  area  of  distribution  of  some  individual  nerve,  it  may 
point  mo8t  suggestively  toward  the  existence  of  some  local  cause  of  irri- 
tation of  that  nerve  itself.  Finally,  Valleix  has  pointed  out  the  situation 
of  certain  regions  in  the  course  of  the  more  important  nerves  of  the 
body  where  extreme  sensitiveness  to  pressure  or  touch  exists  in  con- 


FiG.  (iT.— Diagrammatic  Representation  of  the  Skin  Symptoms  in  Unilateral  Lesion 
OF  the  Dorsal  Portion  of  the  Spinal  Cord  on  the  Left  Side.  (After  Erb, )  The 
diagonal  shading  {a)  signifies  motor  and  vaso-motor  paralysis;  the  vertical  shading  (rfand 
i)  signifies  ana:sthesia  of  the  skin;  the  dotted  shading  (c)  indicates  the  hyperaesthesia  of 
the  sicin. 


nection  with  neuralgic  attacks.  These  are  known  as  the  "  puneta  dolo- 
rosa." They  have  been  separately  described  by  the  author  in  his  work 
entitled  "The  Applied  Anatomy  of  the  Nervous  System." 

Hyperjesthesia  may  be  functional  or  organic.     If  functional ,  it  is 
often  due  to  some  form  of  general  spinal  irritation ;  if  organic,  it  is  com- 


206  LECTURES   ON   NERVOUS   DISEASES. 

moiily  associated  with  more  or  less  anjesthesia.  We  meet  the  organic 
variety  chiefly  in  connection  with  spinal  meningitis,  compression  of  the 
sensory  nerve  roots,  and  locomotor  ataxia. 

Delayed  Sensation. — To  the  beginner  in  medicine  as  well  as  to  the 
laity,  nothing  strikes  the  intelligence  so  forcibly  as  this  symptom  when 
well  marked.  Imagine  a  patient  stuck  with  a  pin,  when  unaware  of  its 
occurrence,  and  an  interval  of  time  (varj-ing  from  one  to  thirty  seconds) 
to  elapse  without  any  consciousness  of  the  wound.  Imagine  the  patient 
then  suddenly  becoming  conscious  of  the  injury  with  all  the  evidences 
of  pain  that  should  have  occurred  without  any  perceptible  interval  of 
time  in  a  healthy  subject.  This  is  delayed  sensation.  It  occurs  chiefly 
in  connection  with  the  disease  known  as  "locomotor  ataxia." 

This  symptom  is  to  be  interpreted  as  an  evidence  of  imperfect  con- 
duction of  sensation  to  the  l)rain  l^y  means  of  the  sensory  nerves  and  the 
so-called  "  sensory  tracts  "  of  the  spinal  cord.  The  sensation  is  not  ar- 
rested "in  toto;"  it  is  simply  delayed.  Complete  abolition  of  sensation 
or  '•ana?sthesia''  is  liable  to  be  developed  later — when  the  nerves  or  sen- 
sory tracts  are  so  extensively  involved  as  to  be  no  longer  able  to  perform 
the  functions. 

SENSIBILITY   TO    TEMPERATURE. 

In  testing  this  variety  of  sensibility,  the  preeautionarv  steps  pre- 
viousl}'  meiitioned  in  connection  with  sensorj'  disturbances  must  be 
carefully  observed. 

Test-tubes  holding  water  of  different  degrees  of  temperature  are  then 
applied  to  the  ditferent  regions  of  the  bodv  which  have  given  previous 
evidences  of  sensory  disturbances,  and  the  patient's  ability  to  discrimi- 
nate between  them  with  accuracy  should  be  noted.  The  temperature  of 
the  test-tubes  should  be  greater  or  less  than  that  of  the  skin  (98|-^)  and 
of  a  uniform  size.  This  prevents  the  confusion  of  simple  ''tactile"  sen- 
sations with  those  of  temperature.  Breathing  upon  the  surface  of  the 
patient  answers  as  a  rough  test  for  the  appreciation  of  heat. 

SENSIBILITY   TO    PAIN. 

The  tests  for  this  variety  of  sensibility  comprise  (1)  pinching  or 
pricking  of  the  skin;  (2)  the  application  of  extreme  heat  to  the  skin; 
and  (3)  the  use  of  a  powerful  faradaic  current  upon  the  skin  with  dry 
electrodes.  The  patient  should  never  be  prepared  for  this  test,  as  he  may 
fail  to  give  external  evidences  of  pain  from  an  assumed  fortitude.  Sen- 
sitiveness to  pain  and  temperature  may  sometimes  be  aflected  when 
tactile  sensations  are  not  impaired. 


THE   SPECIAL   SENSES. 


207 


THE     SPECIAL     SENSES. 

These  comprise  smell,  sight,  hearing,  taste,  and  toiu-h.  The  latter 
has  ahead}'  been  discussed,  and  the  tests  employed  to  detect  abnormalities 
of  the  eye  or  its  muscles  have  been  quite  fully  described. 

Smell. — The  abolition  of  smell,  or  '•'■anosmia,''''  is  to  be  detected  by 
the  following  methods:  (1)  Use  the  same  test  upon  the  nostrils  alter- 
nately; (2)  avoid  all  irritating  substances,  such  as  ammonia,  acetic  acid, 
snutf.  etc. ;  (3)  employ  both  agreeable  and  disagreeable  odors  (cologne, 
camphor,  musk,  etc.,  on  the  one  hand,  and  A-alerian,  turpentine,  asafcetida, 
sulphuretted  h3'drogen,  etc.,  on  the  other);  (4)  employ  odoriferous  sub- 


KiG.  68. — A  Diagram  Designed  by  the  Author  to  Show  Some  of  the  Relations  of 
THE  Optic  and  Olfactory  Nerve  Fibres  to  Surrounding  Parts.  F,  Frontal  lobes 
of  cerebrum:  P,  parietal  lobe;  V,  temporo  sphenoidal  lobe;  S,  fissure  of  Sylvius;  R, 
fissure  of  Rolando;  O,  occipital  lobe;  C,  cerebellum;  M,  medulla  oblongata;  1,  corpora 
quadrigemina ;  2,  optic  tracts;  3,  optic  chiasm;  4,  optic  nerves;  o,  olfactory  nerve;  6, 
motoroculi  nerve  ;  7,  trigeminus  nerve  ;  a,  basis  cruris  ;  b,  tegmentum  cruris.  The  diamonds 
in  the  occipital  lobe  represent  the  cortical  visual  centres  of  Munk.  The  cerebellum  and 
pons  Varolii  are  shown  as  if  separated  from  the  cerebrum,  in  order  to  make  the  relations  of 
the  crus  to  the  optic  tracts  apparent. 


stances  on  the  tongue  (coffee,  wines,  cheese,  etc.),  so  that  the  nose  may 
perceive  them  by  means  of  the  throat,  rather  as  imaginary  taste  percep- 
tions than  as  true  oifactorj'  impressions. 

The   abnormal  acuteness  of  smell,  or  "/i(/peros??ito,"  may  indicate 
brain  disease  that  creates  irritation  of  the  olfactory  nerve.     Nauseating 


208  LECTURES   ON   NERVOI'S   DISEASES. 

odors  to  tlie  henltliy  subject  niay  hecoine  asireeable  to  such  j)aticnts. 
Pleasant  odors,  such  as  those  of  flowers,  ma}'  cause  uauseii.  lieadache,  or 
possibl}^  convulsions. 

Anosmia  has  been  observed  to  accompany  a  congenital  defect  in  the 
olfactory  nerve.  Bell's  paralysis,  tumors  at  the  base  of  the  brain,  absence 
of  the  pituitary  body,  syphilitic  disease  of  the  nose,  hysteria,  insanity, 
paralysis  of  the  fifth  cranial  nerve,  meningitis,  typhoid  fever,  injuries  to 
the  nose  or  skull,  and  nasal  catarrh. 

Hyperosmia  is  commonly  met  with  during  convalescence  from  some 
exhausting  disease,  and  in  connection  with  hysteria,  insanity,  meningitis, 
tumors  of  the  frontal  lobes,  softening  of  the  brain,  epileps}-,  and  adhesions 
of  the  olfactory  bulbs  to  the  dura  mater. 

Sight. — In  connection  with  vision,  in  addition  to  errors  of  refraction 
and  accommodation,  and  the  condition  known  as  "ocular  insufficienc}' " 
(which  have  been  already  discussed  at  some  length),  the  neurologist  is 
chiefly  called  upon  to  detect  the  folloAving  conditions :  (1 )  Paralysis  of  the 
e,ye  muscles  ;  (2)  the  Robertson  pupil;  (3)  the  condition  known  as  ••  hemi- 
anopsia," or,  less  correcth',  "hemiopia;"  (4)  the  condition  of  the  retina 
known  as  "choked  disk;"'  (5)  the  conditions  known  as  "amblyopia''  and 
•'amnurosis." 

ParaJijsis  of  the  Eye  Muscles. — The  attitudes  assumed  by  the 
patient  as  a  result  of  defective  power  in  some  of  its  muscles  have  l)een 
discussed  in  the  second  portion  of  this  chapter. 

Hemianopsia. — This  condition  is  characterized  bj'  a  blindness  of  one 
lateral  half  of  each  eye;  the  unaft'ected  half  of  each  eye  retains  its  power 
of  sight.  The  forms  of  this  condition  that  are  observed,  and  the  tests 
employed  to  detect  it,  have  been  referred  to  already. 

Choked  disk. — This  condition  is  also  known  as  "neuro-retinitis," 
because  the  optic  nerve  and  retina  both  participate  in  the  changes  that 
ensue.     It  has  been  discussed  alread}'  (page  150). 

Robertson''s  Piqnl. — This  condition  is  characterized  by  extremely 
small  pupils  that  contract  for  the  focusing  of  vision  upon  near  objects 
(within  a  radius  of  twenty  feet),  but  do  not  respond  to  A^arying  degrees 
of  light.  The  tests  emploj'ed  to  determine  this  point  have  been  pre- 
viously mentioned  in  the  second  section  of  this  chapter. 

Amblyopia  and  Amaurosis. — These  terms  are  commonly  used  to 
cover  all  the  various  conditions  of  blindness  where  no  organic  changes 
in  the  eye  itself  can  be  seen  to  account  for  them.  The  term  '"amblyopia" 
is  frequently  used  to  denote  a  mild  degree  of  "amaurosis." 

The  more  common  causes  of  these  two  conditions  comprise  (I) 
poisons,  such  as  lead,  tobacco,  and  urea;  (2)  exposure  to  a  prolonged 
glare,  as  in  snow-blindness;  (3)  concussion  of  the  eye;  (4)  irritation  of 
the  fifth  cranial  nerve,  as  in  severe  neuralgia;  (5)  certain  brain  diseases. 


THE   SPECIAL   SENSES. 


209 


Tlic3  latter  are  of  special  interest  in  this  connection.  Several  diagrams 
incorporated  in  this  work  may  prove  of  aid  in  explaining  certain  ana- 
tomical points  that  bear  directly  upon  the  snbject. 

The  following  diagram  (Fig.  69)  shows  that  the  optic  nerve  fibres 
eventually  pass  to  those  regions  of  the  gra^'  matter  on  the  surface  of  the 
brain  (the  cerebral  cortex)  that  are  associated  with  the  intelligent  percep- 
tion of  the  images  focused  upon  the  retina.  But  it  will  be  also  observed  that 
the  optic  nerve  fibres  {o  and  h)  first  pass  through  certain  collections  of 
gray  matter  or  "centres"  within  the  optic  thalami  and  the  corpora  quad- 
rigemina  before  they  radiate  to  the  so-called  "visual  area"  of  the  eon- 
volutions. 

Let  us  now  compare  this  diagram  with  another  (Fig.  21 ),  wliich  will 
make  some  of  these  statements  more  intelligible  to  the  general  reader. 


VISUAL  AREA 

0 


'''BUEs  If 


Fig.  69. — A  Diagram  Designed  by  the  Author  to  Show  the  General  Course  of 
Fibres  in  the  "bENsoRv"  and  "Motor  Tracts"  and  their  Relation  to  Certain 
Fasciculi  of  the  Optic  Nerve  Tracts.  (Modified  from  Seguin. )  S,  Sensory  tract  in 
posterior  region  of  mesocephalon,  extending  to  O  and  T,  occipital  and  temporal  lobes  of 
hemispheres:  M,  motor  tract  in  basis  cruris,  extending  to  P  and  F,  parietal  and  (part  of) 
frontal  lobes  of  hemispheres;  C  Q,  corpus  quadrigeminum ;  O  T,  optic  thalamus;  N  L, 
nucleus  lenticularis  ;  N  C,  nucleus  caudatus;  1,  the  fibres  forming  the  "tegmentum  cruris" 
(Meynert);  2,  the  fibres  forming  the  "  basis  cruris"  (Meynert);  a,  fibres  of  the  optic  nerve 
which  become  associated  with  the  "  optic  centre"  in  the  optic  thalamus,  and  are  subsequently 
prolonged  to  the  "visual  area"  of  the  convolutions  of  the  cerebrum  ;  fi,  optic  fibres  which 
join  the  cells  of  the  "corpora  quadrigemina,"  and  are  then  prolonged  to  the  visual  area  of  the 
cerebral  cortex. 


It  will  help  to  explain  why  it  is  that  pressure  upon  the  optic  tracts,  as 
they  are  called,  causes  hemianopsia  or  blindness  of  one  lateral  half  of 
each  retina. 

Taste. — This  special  sense  is  presided  over  by  the  gustatorv  branch 
of  the  fifth  cranial  nerve,  the  glosso-pharyngeal  nerve,  and  the  chorda 
tympani  branch  of  the  facial  nerve.  Taste  may  be  affected,  therefore,  by 
any  diseased  condition  that  can  cause  either  irritation  or  destruction  of 

14 


210  LECTURES    ON    NERVOUS   DISEASES. 

the  fibres  of  these  nerves.  Certnin  fiiiictiontil  diseases,  in  contradis- 
tinction to  organic  lesions  of  the  lu'ain,  may  also  cause  modifications  of 
taste. 

An  abnormal  sensitiveness  of  taste  is  known  as  "■  hyper gueaia.'''  It 
may  be  developed  in  connection  with  hysteria;  Avitli  melancholia  and 
some  other  types  of  insanity;  and  with  facial  paralysis  of  rheumatic 
origin.  Such  subjects  can  often  detect  extremel}'  small  (luantities  of 
sapid  substances  in  solution,  which  in  health  would  be  unperceived. 
They  may  perceive  gustatory  sensations  when  the  electric  current  is 
a|)plied  over  the  spine  in  the  region  of  the  neck  or  upper  dorsal  verte- 
bra\  They  may  develop  a  loathing  of  certain  dishes  which  have  pre- 
viously been  their  delight,  from  some  imaginary  taste  of  a  disagreeable 
character.  Again,  this  condition  may  express  itself  in  an  unnatural 
enjoyment  of  food.  Fiuall}-,  sweetish,  sapid,  or  sour  tastes  within  the 
mouth  may  be  constantly  present. 

A  loss  of  the  sense  of  taste  is  known  as  '■^  agueniay  It  may  he  com- 
plete or  partial.  Some  regions  of  the  tongue  ma}-  be  affected,  and  others 
retain  the  sense  of  taste.  In  some  instances,  the  tongue  may  be  sensible 
to  certain  substances,  and   insensible  to  others.     It  may  be  associated 


KiG.  70  — Seguin's  Surface  Thermometer. 

with  a  sense  of  burning  and  bitterness  within  the  mouth,  as  in  a  case 
reported  by  Bottcher,  where  a  tumor  at  the  l)ase  of  the  brain  was  its 
exciting  cause. 

This  abnormal  state  has  been  observed  to  follow  the  development  of 
tumors  of  the  brain  or  its  coverings;  paralysis  of  the  fifth  cranial  nerve; 
sclerosis  of  the  medulla  oblongata;  injuries  to  the  glosso-pharyngeal 
nerves;  atrophy  of  the  nerves  associated  with  taste;  and  ear  disease 
causing  pressure  upon  the  chorda  tj'mpani  branch  of  the  facial  nerve. 

Hearing. — The  mechanism  of  the  ear  is  so  complicated  that  defects 
in  hearing  are  con^monly  due  to  some  abnormal  condition  of  the  ap- 
paratus itself,  rather  than  of  the  nerve  of  hearing  or  the  brain.  Perhaps 
the  most  reliable  test  to  determine  the  presence  of  the  latter  condition  is 
the  employment  of  the  tuning-fork.  If  this  instrument  be  set  in  vibration 
and  applied  to  the  teeth,  or  the  bones  of  the  skull,  the  transmission  of 
the  sound-waves  through  the  bones  will  enable  them  to  reach  the  nerve 
filaments  of  the  internal  ear,  and  aftbrd  the  patient  perceptions  of  sound. 
If  the  patient  is  unable  to  peceive  sound  when  thus  conducted  to  the 
nerve  filaments,  it  is  strongly  suggestive  of  some  diseased  condition 
within  the  envit^•  of  the  skull. 


CEREBRAL   THERMOMETRY. 


•Jll 


CEREBRAL     THERMOMETRY. 

Within  a  few  years  inucli  attention  has  been  given  to  the  temperature 
of  limited  portions  of  tlie  skull  in  health  and  disease  (Broea,  Hammond, 
Segnin,  Amidon,  Gray,  and  others).  Many  forms  of  instruments  may  be 
employed  for  this  purpose.  Probably  the  simplest  and  least  expensive  is 
the  surface  thermometer  devised  by  Seguin,  which  has  a  large  flattened 
liulb  well  adapted  to  insure  close  contact  with  the  scalp.  Any  number 
i)f  such  thermometers  may  be  fastened  to  a  shaven  scalp  b}'  means  of  per- 
forated straps  (Gray)  or  an  India-rubber  cap  similarly  perforated.  The 
effect  of  the  temperature  of  the  air  upon  the  mercury  may  be  avoided 
by  coating  the  parts  not  in  contact  with  the  scalp  with  shellac. 


Fig.  71. — Thermo-electric  Differential  Calorimeter.— Connect  the  two  thermostats  as 
shown  in  figure,  viz.:  connect  by  means  of  one  of  the  metal  tipped  cords  one  binding-post  of 
each  of  the  thermo-piles  to  the  two  bindinsj-posts  on  base  of  the  galvanometer.  Then  con- 
nect the  two  remaining  posts,  one  on  each  of  the  thermo-piles  with  each  other.  After  so 
doing,  place  the  thumb  on  the  face  of  one  .if  the  thermo-piles  and  observe  the  direction  of  the 
deflection  of  the  galvanometer  needle,  then   place    thumb  on   face  of  the  other  thermo-pile, 

,  leaving  the  first  uncovered,  and,  if  the  deflection  is  in  the  opposite  direction  to  that  first  ob- 
tained, the  instruments  are  properly  connected.  If,  however,  the  second  deflection  is  in 
same  direction  as  obtained  by  pressing  thumb  on  first  thermopile,  disconnect  the  two  cords 
from  either  thermo-pile  and  interchange  them,  viz.:  take  cord  from  right-hand  post  and 
place  in  left,  and  cord  from  left  post  and  place  in  right-hand  post  :  the  deflections  will  then 
be  as  first  alluded  to,  one  pile  turning  needle  in  one  direction  and  the  other  in  the  opposite 
direction. 


More  delicate  tests  of  temperature  may  be  obtained  by  the  thermo- 
electric calorimeter  devised  by  Lombard.  One  or  two  minutes  is  only 
required  by  this  instrument  to  detect  variations  in  the  temperature  of 
liomologous  regions  of  the  scalp,  but  it  is  expensive  and  only  available 
for  use  in  the  office. 


212  LECTUKES   ON   NEllVOUS   DISEASES. 

It  is  essential  tluvt  two  tliennoiiictcrs  :it  least  be  enii)loyed  when  the 
thermometry  of  the  scalp  is  being  tested,  in  order  that  the  temperatnre 
of  homologous  parts  of  the  two  hemispheres  may  be  simultaneously  taken, 
thus  insuring  tlie  same  conditions  of  vascular  supply.  A  comparison 
should  alwa3's  be  made  between  tlie  results  so  obtained,  before  any 
clinical  deductions  can  be  drawn  from  them. 

The  temperature  of  the  scalp  seems  to  )>e  somewhat  Ijelow  the 
normal  standard  of  health  (98.5°  Fahr.)  in  all  of  its  parts. 

Amidon  has  shown  that  willed  muscular  movements  if  continued  for 
some  time  are  associated  with  an  increase  of  heat  over  the  cortical  centres 
which  are  called  into  action.  He  has  thus  confirmed  some  of  the  deduc- 
tions obtained  by  physiological  experiments  upon  animals.  Gray  and 
Mills  report  the  diagnosis  of  a  tumor  of  the  In-ain  by  the  detection  of  a 
localized  elevation  of  temperature  over  the  area  involved.  The  differ- 
ence between  the  healthy  and  unhealthy  side  w^as  about  one  degree  and  a 
half  Hamilton  reports  a  case  where  a  difference  of  three  degrees  ex- 
isted, and  persisted  at  repeated  examinations ;  the  case  was  living  at  the 
date  of  this  statement,  so  that  the  diagnosis  of  tumor  had  not  been  posi- 


FiG.  72. — Duchenne's  Trochar.     a, Open;  <^,  closed. 

tively  verified.  From  my  own  experience,  I  am  led  to  believe  that  an 
unilateral  deviation  of  one  and  a  half  or  two  degrees  above  or  below  the 
normal  point,  within  a  circumscribed  area  of  the  scalp,  wdiich  is  per- 
sistent and  unattended  with  as  marked  a  rise  or  fall  in  temperature  in 
adjacent  areas,  must  be  regarded  as  a  valuable  diagnostic  symptom  of 
disease  within  that  area.  If  it  be  a  cerelu-al  tumor,  I  should  expect  to 
find  b}' the  ophthnlmoscope  the  characteristic  evidences  of  neuro-retinitis, 
known  as  the  "choked  disk." 

Sometimes  it  is  very  important  to  decide  as  to  the  existence  of  or- 
ganic changes  in  the  muscular  tissue  of  diflerent  parts  of  the  body.  By 
means  of  this  very  ingenious  and  useful  instrument  we  are  enabled  to 
extract  with  little  pain,  and  no  danger,  small  pieces  of  any  muscle  which 
can  be  examined  microscopically  at  your  leisure.  This  instrument  is 
introduced  (with  the  slide  open)  into  the  substance  of  the  muscle;  sub- 
sequently the  slide  is  closed  and  the  instrument  is  then  Avithdrawn.  A 
small  piece  of  the  muscle  Avill  be  found  to  have  been  removed  and  re- 
tained within  the  instrument. 


CEREBRAL   THERMOMETRY.  213 

In  closing  this  cluipter,  tiie  author  feels  that  he  has  perhaps  over- 
taxed the  patience  of  his  readers.  If  he  has  erred  in  this  direction,  it  is 
because  he  has  endeavored  to  cover  a  large  field  within  the  limited  com- 
pass of  a  single  chapter,  and  to  so  interpret  the  symptoms  of  nervous 
diseases  as  to  bring  them  within  the  grasp  of  the  general  practitioner  of 
medicine.  It  must  not  be  inferred  that  all  of  the  tests  described  are  of 
necessity  demanded  in  each  individual  case  that  is  brought  to  the  notice 
of  the  neurologist.  As  Gower  happily  remarks.  "  To  know  our  enemy  is, 
if  not '  half  the  battle,'  at  least  an  important  part  of  it."  When  once  the 
symptoms  of  nervous  diseases  have  been  thoroughly  mastered,  the  special 
lines  of  investigation  demanded  in  each  case  become  as  clearly  defined 
as  does  the  course  of  his  vessel  to  the  mariner,  to  reach  the  harbor  for 
which  he  steers.  This  chapter  gives  but  the  rough  outlines  of  a  chart  in 
which  the  short  cuts  to  valuable  information  in  diagnosis  are  imi)erfectly 
jotted.  Arduous  and  persistent  labor  on  the  part  of  each  of  its  followers 
can  alone  fill  in  its  details  and  render  it  complete. 


SECTION  HI, 


DISEASES   OF   THE   BRAIN   AND   ITS 
ENVELOPES. 


SECTION  III. 


DISEASES    OF   THE   BRAIN    AND    ITS   ENVELOPES. 


Diseases  of  the  brain  are,  i)erliaps,  in  many  cases,  tlie  most  difHcult 
t.)  recoi^nize  witli  certainty  during  life  of  any  that  the  physician  encoun- 
ters. The  results  of  autopsies  go  to  prove  that  serious  errors  in  diagnosis 
are  too  ofteu  made  in  connection  with  cerebral  affections.  In  occasional 
instances,  such  errors  are,  perhaps,  unavoidable;  but  many  that  are  con- 
stantly made  might  unquestionably  have  lieen  avoided  had  more  study 
been  given  to  the  peculiar  features  of  each  disease,  and  greater  care 
exei'cised  in  the  clinical  examination  of  the  i)atient. 

In  the  two  preceding  sections  we  have  discussed  at  considerable 
length  the  anatomical  and  physiological  bases  of  cerebral  localization; 
and  also  the  various  tests  Avhich  may  be  demanded  from  time  to  time 
during  the  clinical  examination  of  a  patient.  We  are  now  prepared  to 
intelligently  discuss  separate  diseases  of  the  nervous  system  from  the 
clinical  aspect. 

Too  great  stress  cannot  be  laid  upon  the  necessity  of  a  thorough 
familiarity  with  the  two  preliminary  sections  of  this  work.  Constant 
reference  will  be  made  by  me  to  many  facts  and  deductions  incorporated 
;uid  interpreted  in  those  chapters. 

The  following  talile  may  aid  the  reader  in  classifying  the  more 
important  diseases  of  the  brain  and  its  envelopes: — 

Abnormal  Conditions  of  the  Brain  and  its  Envelopes. 


1.  Congenital 
Defects     or 

Malformations 
OF  the  Brain 
AND  Cranium. 


Double-head. 

Fusion  of  two  heads. 

Absence  of  brain  or  head. 

Cyclocephalic  deformity. 

Abnormalities  of  ihe  cerebral  envelopes. 

Incomplete  development  of  special  ganglia. 

Hydrocephalus. 

Encephalocele. 

Aneurisms. 

Atheroma. 


2.  Diseases    af- 
fecting   the 
Vessels  of  the  ' 
Brain. 


Arterial  thrombosis,    . 

\^enous  thrombosis. 

Embolism. 

Aphasia. 

Cerebral  hypersemia,  .    . 

Cerebral  atia?mia,     .    . 
Apoplexy — Cerebi'al  hemorrhage. 


(Affecting  sinuses  and  large 
vessels. 
Capillary  variety. 


S  Active  variety. 

(  Passive  variety. 

S  Localized  variety. 

(  General  varietj'. 


(217) 


218 


LECTURES    ON   NEEVOUS   DISEASES. 


3.  i  n  f  l  a  m  m  a- 
t  0  r  v  c  o  x  u  i  - 
tioxs  of  th k 
Brain. 


Abn'oumvl  Coxurrioxs  of  the  Hiiaix  axu  its  Exvelopes  (continued). 

Pachymeningitis j  Suppurative  variety. 

-  (  ^on-sujijtur.  variety. 

j  Acute. 

Meningitis -l  Sub-acute. 

L  Chronic. 

II    J  1    1       /     u        1  ■  ^       ^  Acute. 

Hydrocephalus  (tubercular  meningitis).  .    <  Chronic 

.Encejihalitis. 


4.  Structtral 
Changes  of 
the      b  r  a i x  - 

TISSUES. 


)t'tening, 


Red. 

Wliite. 

Yellow. 


Abscess, ,4^^"^^-. 

(  Chronic. 

{General  variety. 
Multiple  variety. 
Miliary  variety. 


Atrophy, 


Infantile  variety. 
Senile  variety. 


5.   Cerebral 
Tumors. 


Carcinoma.  i— cv^l^.^^ 

Lipoma. 
Glioma. 
Myxoma. 
Papilloma. 
Melanoma. 
Sarcoma. 
Gummata. 
Psammoma. 
Cholesteatoma. 
Tubercle. 
Fibrous. 
Fibro-plastic. 
1^  Parasitic. 


CONGENITAL    MALFORMATIONS    OR   DEFECTS    OF   DEVELOPMENT.* 

Defects  in  development  of  the  central  nervous  system  (which  are 
occasionally  observed  in  connection  with  congenital  malformations)  are 
being  studied  to-day  with  great  interest,  both  by  anatomists  and  physi- 
ologists. Sections  of  such  brains,  when  properly  prepared  and  stained, 
are  often  very  instructive,  because  they  shed  more  or  less  light  upon  the 
course  and  connections  of  tracts  of  fibres  whose  functions  are  in  many 
cases  more  or  less  imperfectly  understood. 

The  following  paragraphs  relate  to  those  defects  which  may  be 
observed  in  the  human  brain  as  a  result  of  imperfect  development : — 

Two  heads  liaA-e  been  repeatedly  met  with  upon  the  same  body. 
They  may  be  either  distinct  or    joined    laterally  or   anteriorly.     They 

*  Portions  of  this  chapter  have  been  incorporated  by  the  author  in  the  third  edition 
of  his  work,  entitled,  "  A  Practical  Treatise  on  Surgical  Diagnosis,"  N.  Y.,  1884. 


DISEASED   CONDITIONS   OF   THE   CEREBKAL   VESSELS.  219 

may  assume  different  sizes  and  sluipes,  and  may  exhibit  different 
degrees  of  development. 

An  entire  absence  of  tlie  br:iin  at  l)irtli,  and,  in  some  instances,  of 
the  s{)inal  cord  in  part,  has  not  infrequently  been  recorded. 

The  cerebrum,  cerebellum,  pons  Varolii,  medulla  oblongata,  and 
even  a  part  of  the  spinal  cord,  may  be  occasionally  wanting,  and  yet  the 
cranial  nerves  may  l>e  perfectly  developed. 

In  rare  instances,  the  base  of  the  skull  has  been  exposed  to  view. 
In  others,  the  upper  cranial  bones  have  been  wanting,  and  the  integu- 
mentary covering  of  the  head  has  been  found  to  be  distended  by  a  fluid 
accumulation  beneath  it.  In  some  cases  reported,  only  parts  of  the 
brain  have  been  absent,  the  remaining  ganglia  being  normally  developed. 

The  condition  termed  "  Cyclocephalous  " — due  to  a  fusion  of  the  two 
orbits  into  one  cavity — is  sometimes  encountered. 

The  meninges  may  be  occasionally  found  to  be  incomplete.  The 
falx  and  tentorium  may  be  wholly  or  partially  absent,  or  may  be  perfo- 
rated with  holes.  The  dura  is  sometimes  wanting  at  the  base  of  the 
skull. 

The  corpus  callosum,  fornix,  and  septum  lucidum  have  been  found 
wanting  in  the  brains  of  some  idiots.  The  optic  nerves  have  sometimes 
no  commissure. 

The  whole  brain  may  be  occasionally  so  small  as  to  constitute 
the  "  microcephalous  state.''''  Again,  only  certain  convolutions  may 
exhibit  arrested  development,  and  a  cyst  filled  with  serum  is  then 
found  to  commonly  spring  from  the  meninges  and  fill  the  space  thus  left 
vacant. 

The  two  hemispheres  of  the  cerebrum  may  present  extreme  variation 
in  point  of  size  and  weight.  The  thalami  and  corpora  striata  ma}' 
occasionally  exhibit  atrophy. 

The  brain  may  occasionally  protrude  from  the  cavity  of  the  cranium 
at  the  various  sutures  or  fontanelles, — constituting  ^^ encephalocele.'^ 

Finally,  the  '■^hydrocephalic  condition^''  may  exist  (characterized  by 
excessive  fluid  outside  of  or  within  the  ventricles  of  the  brain).  It 
usually  tends  to  increase  after  birth. 

The  various  types  of  congenital  malformations  of  the  nerve  centres 
which  are  encountered  seem,  as  a  rule,  to  depend  either  upon  some 
violence  to  the  uterus  or  some  mental  shock  to  the  mother  during 
pregnanc3^ 

DISEASED  CONDITIONS  OF  THE  CEREBRAL  VESSELS. 

Under  this  heading  may  be  included  the  following  conditions : 
Aneurismal  dilatations  ;  atheromatous  and  calcareous  changes  ;  rupture 
or  spontaneous  perforation  of  blood-vessels  ;  thrombosis  of  the  arteries 


220 


LECTURES   ON    NERVOUS   DISEASES. 


or  sinuses  of  the  brain  or  its  coverings ;  embolism  ;  fibroid  degeneration  ; 
hyperjvmia ;  antemia ;  and  to  inflammatory  c-lianges  in  tlie  coats  of 
blood-vessels. 

ANEURISMAL  DILATATIONS. 

The  vessels  within  the  skull  most  frequently  atlected  are  the  in- 
ternal carotid,  basilar,  and  middle  cerebral.  Within  the  cavernous  sinus, 
large  aneurismal  tumors  are  not  uncommon.  It  must  not  be  supposed, 
however,  that  the  smaller  vessels  of  the  brain  are  exempt.  Miliary 
aneurisms,  which  sometimes  give  to  an  artery  and  its  branches  an 
appearance  resembling  a  bunch  of  grapes,  frequently  affect  the  vessels 
that  form  the  circle  of  Willis,  and  even  those  of  the  pia-mater,  within 


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Fig.  7.3. — A  Miliary  Aneurism  of  the  Cerebral  Cortex — Anterior  to  Roland's 
Fissure  (3.)0  diameters) .  This  beautiful  drawing  was  kindly  made  from  a  microscopic 
slide  by  my  friend  Dr.  G.  Van  Schaick,  of  New  York.     {P,  pro.ximal  end;  D,  distal  end.) 


the  substance  of  the  brain  and  in  the  ventricles.  The  small  vessels 
which  nourish  the  corpora  striata  and  the  optic  thalami  are  sometimes 
affected. 

Miliar}'  aneurisms  of  the  brain  frequently  coexist  with  aneurismal 
tumors  of  larger  vessels  outside  of  the  cranium  ;  but  thevseem  to  exhibit 
an  independence  of  atheroma  which  is  quite  remarkable. 

Morbid  Anatomy. — Those  who  have  devoted  Special  attention  to  this 
subject — Ciiarcot.  Zenker,  Bouchard,  Meynert,  Hammond,  and  others — 
differ  regarding  the  cause  of  these  dilatations.  Some  regard  them  as  due 
to  a  "  sclerosis  of  the  tunica  intima  "  of  the  arterioles.  Others  believe 
that  small  "  dissecting  aneurisms"  (this  tei-m  covers  all  those  tj'pes  of 


ATHEROMA.  221 

aneurism  where  the  blood  escapes  between  the  coats  of  an  artery  for  a 
greater  or  less  distance)  first  form,  because  of  a  rupture  of  the  inner  coat. 
When  the  external  coat  of  such  an  aneurism  ruptures,  a  cerebral  hemor- 
rhage ensues.  The  fact  that  miliary  aueurisms  affect  all  ages  (since  even 
children  are  not  exempt)  seems  to  me  to  point  to  an  "  aneurismal  dia- 
thesis "  as  an  exciting  cause  in  some  instances.  If  such  be  the  case,  the 
arterial  coats  would  exhibit  under  a  microscopic  lens  marked  congenital 
defects  in  their  construction. 

Etiology. — Among  the  other  exciting  causes  of  cerebral  aneurism 
may  be  mentioned  the  cachexia  of  cancer ;  tuberculosis ;  uraemic  poison- 
ing ;  chronic  alcoholism;  lead  poisoning ;  loucocythjpmia  ;  rheumatism; 
gout ;  sypliilis  ;  and  general  paralysis.  The  remarkable  tendency  of 
alcohol  to  excite  aneurismal  tendencies  (not  only  in  the  brain  and  retina, 
but  in  other  parts  as  well)  is  adduced  by  some  authors  as  an  argument 
in  favor  of  the  view  that  arterio-sclerosis  precedes  and  causes  the  altera- 
tions in  the  calibre  of  the  vessels. 

In  case  cerebral  aneurisms  be  of  large  size,  atlieromatous  or  cal- 
careous changes  within  the  arterial  coats  are  seldom  absent. 

Symptoms. — Miliary  cerebral  aneurisms  give  rise  not  infrequently  to 
headache  and  vertigo.  Attacks  of  paralysis  which  follow  one  another 
rapidly,  and  from  which  the  patient  quickly  recovers,  may  be  regarded 
as  almost  a  positive  proof  of  their  existence. 

These  small  aneurisms  produced  their  motor  effects  only  by  rupture. 
Minute  extravasations  into  the  brain-tissue  commonly  occur  at  first ;  but 
later  on  large  apoplectic  clots  may  be  formed.  The  discussion  of  the 
symptomatology  of  cerebral  hemorrhage  will  occupy  subsequent  pages 
of  this  volume.  A  previous  section  of  this  work  also  covers  many  sug- 
gestions of  an  anatomical  and  clinical  nature  that  bear  upon  cerebral 
localization. 

ATHEROMA. 

Tbe  cerebral  vessels  may  participate  in  a  peculiar  form  of  degenera- 
tive change,  termed  atheroma.  When  this  condition  is  developed,  ves- 
sels in  other  parts  of  the  body  are  usually  affected  simultaneous!}-. 

Morbid  Anatomy. — The  changes  observed  in  the  cerebral  vessels, 
when  atheromatous,  seem  to  be  produced  slowly. 

The  extent  to  which  it  affects  the  blood-vessels  admits  of  large  vari- 
ation. In  some  instances  every  vessel  named  by  anatomists  is  thus  dis- 
eased, while,  in  others,  only  certain  vessels,  and  even  parts  of  vessels,  are 
found  to  he  affected.  In  extensively  developed  atheroma,  a  symmetrical 
condition  is  usually  present  on  the  two  sides.  This  fact  is  of  importance 
in  some  cases,  since  a  guide  to  diagnosis  may  be  thus  afforded.  Cases, 
which  have  often  been  reported,  of  parallel  and  contemporaneous  popli- 


222  LECTURES    ON   NERVOUS   DISEASES. 

teul  aneurisms  in  the  same  person  illustrate  well  the  tendency  toward  a 
symmetrical  develoi)ment  in  tlie  limbs. 

Atheroma  develops  more  often  in  the  lower  liml)s  than  in  the  upper, 
and  the  extent  of  its  progress  seems  to  be  greater  when  situated  below 
the  diaphragm  than  when  above  it. 

It  is  a  direct  result  of  an  existing  chronic  endarteritis,  the  lining 
membrane  of  the  vessels  being  invariably  involved  to  a  greater  or  less 
degree.  It  is  most  frequently  found  in  the  arteries,  although  the  veins 
may  develop  an  atheromatous  condition  when  exposed  to  any  source  of 
prolonged  irritation.  It  is  also  developed  in  the  male  sex  in  far  greater 
proportion  than  in  females,  and  is  apparently  influenced  to  some  extent 
b}^  climate. 

As  a  result  of  this  condition  the  affected  vessel  becomes  impaired 
in  its  contractile  power,  loses  its  natural  tone,  and,  in  consequence  of  its 
inability  to  sustain  its  accustomed  internal  pressure,  undergoes,  in  many 
cases,  dilatation  at  the  seat  of  the  disease. 

Etiology. — This  condition  may  be  produced  by  age,  chronic  alcohol- 
ism, gout,  rheumatism,  lead  poisoning,  syphilis,  chronic  diseases  of  the 
kidney,  exposure,  or  traumatism. 

Symptoms. — When  the  condition  of  atheroma  is  once  developed, 
rings  of  ossification  are  often  perceptible  along  the  course  of  the 
superficial  vessels.  An  abnormal  tortuosity  of  the  arter3'  is  not  in- 
frequently'^ present,  if  the  atheromatous  condition  is  diflused  for  some 
distance. 

The  existence  of  atheromatous  changes  is  not  always  to  be  detected, 
however,  even  in  the  superficial  vessels  of  the  extremities,  by  the  sense 
of  touch.  Diminished  arterial  volume,  and  an  impaired  nutrition  to 
tissues  when  an  excessive  arterial  supply  is  demanded  (as  occurs  in 
inflammatory  processes)  are  frequentl}'  points  of  value  in  the  diagnosis 
of  an  atheromatous  condition.  Atheroma  has  especial  medical  import- 
ance on  account  of  a  tendency  which  it  creates  toward  rupture  of 
the  affected  vessels,  either  from  an  ulcerative  destruction  of  their  coats 
or  from  the  rigid  and  brittle  condition  of  the  walls  of  the  vessel  pro- 
duced b^^  the  calcareous  deposits. 

The  dangers  whicii  result  from  atheromatous  changes  within  the 
coats  of  the  cerebral  vessels  render  the  detection  of  these  changes  im- 
portant, even  if  the  disease  be  unassociated  with  marked  external  evi- 
dences of  its  existence. 

It  must  be  remembered  that  the  process  of  repair  cannot  be  per- 
fected in  an  artery-  whose  lining  membrane  is  tough  or  osseous,  or  in  a 
state  of  fatty  degeneration,  whose  middle  coat  has  atrophied,  and  whose 
contractility  is  destroyed. 

One  important  point  in  diagnosis  in  this  connection  has  lately'  been 


CEREBRAL    THROMBOSIS.  223 

brought  to  professional  notice,  viz.,  that  hi-temporal  hemianopsia  indi- 
cates in  most  cases  an  atheromatous  change  in  the  vessels  composing 
the  circle  of  Willis.  This  subject  has  been  discussed  lately,  under  the 
head  of  "Lesions  affecting  the  Optic  Nerve." 

CEREBRAL    THROMBOSIS. 

A  coagulum  of  blood  may  form  in  either  the  sinuses,  veins,  or 
arteries  of  the  brain.  Some  changes  in  the  coats  of  the  vessels,  however, 
usually  pi'ecede  and  cause  the  development  of  such  a  coagulum.  The 
vessels  are  therefore  occluded  gradually.  This  is  in  marked  contrast 
to  embolism,  which  causes  a  sudden  occlusion  of  a  vessel  whose  coats 
raa^^  be  perfectly  healthy. 

Morbid  Anatomy. — Thrombosis  is  much  less  common  in  arteries 
than  in  venous  channels ;  but  it  is  not  uncommon  in  the  internal  carotid, 
the  vertebral,  the  basilar,  and  the  middle  cerebral  arteries.  In  the 
superior  longitudinal  and  lateral  sinuses  thrombosis  is  frequently  found ; 
chiefly  in  connection  with  pachymeningitis.  Old  age  seems  to  predis- 
pose to  the  development  of  cerebral  thrombosis ;  and  males  are  more 
commonly  affected  than  females.  Cerebral  thrombosis  in  children  may 
develop  in  connection  with  exhausting  diarrhoea. 

The  effect  of  thrombosis  of  arteries  or  veins  within  the  cavity  of 
the  cranium  is  to  render  tlie  nutrition  of  surrounding  parts  more  or  less 
imperfect,  and  thus  to  impair  the  function  of  those  parts.  If  it  be  of 
pyaemic  origin  the  thrombosis  may  cause  siqypuration  of  the  adjacent 
structures ;  and,  by  its  disintegration,  other  vessels  more  or  less  distant 
from  the  seat  of  the  original  thrombus  may  become  plugged  by  the 
detritus.  Metastatic  abscesses  in  the  viscera  are  produced  in  this 
way. 

Etiology. — The  causes  which  chiefly  tend  to  produce  thrombosis 
include  (1)  atheroma,  ^\\\c]\  produces  a  roughened  condition  of  the 
internal  coat  of  the  blood-A'essels ;  (2)  hyperinosis,  or  that  condition  of 
the  blood  in  which  a  marked  excess  of  fibrrneis  present,asin  some  acute 
diseases,  of  which  inflammatory  rheumatism  stands  foremost;  (S)  pj-es- 
sure  upon  some  lai^ge  vessel  or  sinus,  so  that  the  circulation  within  it  is 
rendered  extremely  slow  ;  (4)  chronic  interstitial  nephritis;  (5)  syphilis ; 
and  (6)  pyaemia,  which  seems  to  be  associated  witli  a  special  tendency 
toward  spontaneous  coagulation  of  blood  within  the  vessels,  when  the 
rapidity  of  the  current  is  slowed. 

Symptoms. — The  symptoms  produced  by  cerebral  thrombosis  must, 
of  necessity,  be  modified  by  the  situation  of  the  clot  and  the  vessel 
occluded  by  it.  A  knowledge  of  the  functions  of  different  portions  of 
the   brain  can    alone    decide  questions   which  may   arise   in   any   indi- 


224  LECTURES   ON  NERVOUS   DISEASES. 

vidual  case  respecting  the  situation  and  the  probable  termination  of  the 
lesion.  Either  coma  or  paralysis  (in  any  of  its  forms)  is  apt  to  be 
one  of  the  results.  It  is  liable  to  be  confounded  chiefly  with  cerebral 
embolism  or  cerebral  hemorrhage.  Cerebral  softening,  which  ma^'  be 
one  of  its  sequelae,  will  be  treated  of  as  a  separate  affection  in  this 
volume. 

It  must  be  remembered  that  sypl)ilis  and  chronic  nephritis  are 
among  the  most  frequent  of  the  causes  of  arterial  thrombosis.  This  fact 
is  ex2:)lained  by  the  development  of  an  inflammatory  condition  of  the 
internal  coat  of  the  vessel, — the  so-called  "  endarteritis  obliterans.''^  For 
this  reason  the  history  of  the  patient  may  prove  an  important  factor  in 
the  differentiation  between  cerebral  thrombosis  and  some  other  conditions 
of  the  brain  which  might  be  mistaken  for  it. 

Cases  where  cerebral  thrombosis  has  existed  during  life  and  yet  been 
unrecognized  by  many  medical  men  of  note  confirm  the  statement  that  an 
accurate  diagnosis  of  this  condition  is  a  matter  of  extreme  uncertaint}' 
in  some  instances. 

The  symptoms  of  the  conditions  are  modified  in  ever}^  case  (1)  by 
the  seat  of  the  blood-clot,  and  (2)  by  the  amount  of  interference  with  the 
circulation  that  ensues  in  surrounding  parts.  Furthermore,  serious  effu- 
sion may  occur  (in  some  cases)  from  neighboring  vessels,  provided  the 
circulation  in  adjacent  parts  is  rendered  imperfect.  This  may  tend  to 
mask  the  symptoms  of  the  primary  condition. 

To  enter  into  detail  respecting  all  the  phenomena  that  ma}-  be 
encountered  in  connection  with  cerebral  thrombosis  would  necessitate 
the  discussion  of  the  entire  subject  of  cerebral  localization.*  Hints  may 
be  given,  however,  that  may  shed  some  light  upon  cases  of  this  character. 
None  of  these  suggestions  are  to  be  considered,  however,  as  pathogno- 
monic of  this  condition. 

Thrombosis  of  the  lateral  sinuses  may  be  attended,  according  to  the 
observations  of  Gerhardt,  with  a  difference  in  the  size  of  the  external 
jugular  veins. 

If  thrombosis  occurs  in  the  transverse  sinus  a  circumscribed  oedema 
of  a  painful  character  may  develop  behind  the  ear,  provided  the  veins 
leading  to  the  sigmoid  fossa  are  implicated. 

Epistaxis  may  occur  when  the  superior  longitudinal  siiius  is  thus 
plugged.  A  complicating  oedema  of  the  forehead  and  the  development 
of  exophthalmus  has  been  reported  from  the  same  cause. 

Suppuration  of  the  ear  not  unfrequently  occurs  when  the  petrosal  or 
cavernous  sinuses  are  implicated. 

A  thrombus  of  one  of  the  larger  arteries  of  the  brain  may  produce 
sudden  angemia  of  the  parts  nourished  by  its  branches,  and  thus  induce 
*  See  closing  pages  of  Section  I. 


CEREBKAL   THEOMBOSIS. 


225 


paralysis  of  motion  or  sensation,  or  botli.  Convulsions,  disturbances  of 
the  special  senses,  and  coma  may  also  follow.  The  ocular  muscles  may 
be  rendered  paretic,  thus  causing  strabismus  and  diplopia. 

Localized  passive  hyperiemia  may  be  one  of  the  effects  of  cerebral 
thrombosis,  and  thus  give  rise  to  a  train  of  symptoms  indicative  of  that 
condition.     (See  subsequent  pages.) 

Thrombosis  may  go  on  to  suppuration.  In  such  a  case  the  symp- 
toms of  cerebral  abscess  or  of  general  pyaemia  may  develop.  In  a 
brochure  upon  this  subject  *  I  reported  two  cases  which  came  under  my 


Fig.  74. — A  Diagram  Designed  by  the  Author  to  Show  the  Cerebral  Sinuses  in  Profile. 
1,  superior  longitudinal  sinus  :  2,  inferior  longitudinal  sinus  ;  3,  straight  sinus,  deriving  blood 
from  1  and  also  from  the  veins  of  Galen  (11)  :  Nos  1,  2  and  3  bound  the  falx  cerebri; 
4,  the  torcular  Herophili,  where  four  sinuses  meet;  o,  lateral  sinus;  6,  superior  petrosal 
sinus,  joining  the  lateral  sinus  (.J)  with  the  cavernous  sinus  {>■)  ;  7,  inferior  petrosal  sinus, 
joining  the  cavernous  sinus  (8)  with  the  jugular  vein  (9)  ;  t',  cavernous  sinus:  9,  internal 
jugular  vein  formed  by  two  sinuses  (5  and  7) ;  10,  occipital  sinus;  11,  vena:Galeni;  12,  vein 
passing  to  nasal  cavity  ;  13,  foramen  ca;cum. 


personal  observation,  where  a  trivial  contusion  of  the  scalp  which  failed 
to  break  the  skin  had  induced  thrombosis  of  the  diploe  and  caused  death 
by  pyaemia.  The  autopsies  showed  extensive  secondary  thrombosis  of 
the  cerebral  sinuses  and  metastatic  abscesses  in  nearly  every  organ  of 
the  body. 

In  children  exhaustive  diarrhoea  may  induce  thrombosis  of  the  cere- 
bral sinuses.  We  may  expect  to  encounter  in  such  a  case  rigidity  of 
muscles  of  the  neck,  and  sometimes  of  the  back  and  limbs  ;  the  develop- 

*  Pycemia  and  Sepfictrmia.     Amials  of  Anatomy  and   Surererv,  Nov.,  1881.     A  lecture 
delivered  by  the  Author  before  the  Anatomical  and  Surgical  Society  of  Brooklyn,  N.Y. 

15 


226 


LECTURES   ON   NERVOUS   DISEASES. 


meiit  of  nystagmus,  ptosis,  or  strabismus,  facial  paresis  (in  some  cases), 
and  somnolence,  coma  and  collapse.  It  is  well  to  state,  however,  that 
these  symptoms  are  not  pathognomonic  of  cerebral  thrombosis  in  a  child. 
They  may  indicate  only  a  state  of  general  cerebral  anaemia. 

Differential  Dragnosis. — The  proT)able  cause  of  the  thrombosis  must 
be  taken  into  consideration  in  connection  with  the  symptoms  presented 
by  each  case.     Both  may  assist  greatly  in  the  diagnosis.     If  the  throm- 


FiG.  75. — A  Diagram  Designed  by  the  Author  to  Show  the  Venous  Sinuses  of  the 
Dura-Matek,  as  Seen  after  a  Horizontal  Section  through  the  Cranium.  A, 
anterior  fossa  of  skull ;  />,  middle  fossa  ;  C,  posterior  fossa;  J^  S,  frontal  sinus:  1,  torcular 
Herophili ;  2,  2,  lateral  sinuses;  3,  3,  occipital  sinuses  ;  4,  4,  superior  petrosal  sinuses  ;  5,  5, 
inferior  petrosal  sinuses;  6,  transverse  sinus  ;  7.  7.  cavernous  sinuses;  8,  circular  sinus  ;  9, 
opening  into  internal  jugular  vein;  10.  ophthalmic  vein,  comrnunicatins;  with  cavernous 
sinus  (7)  ;  11,  a  branch  joining  the  occipital  and  inferior  petrosal  sinuses;  12,  veins  from 
posterior  condyloid  foramen  to  lateral  sinus. 


bus  be  due  to  a  tumor  within  the  cranium  it  will  perhaps  be  impossible 
to  separate  the  symptoms  of  each.  It  is  Avell  to  know  that  thrombosis 
has  been  known  to  follow  rheumatism,  erysipelas,  a  carbuncle  of  the 
neck,  some  of  the  fevers,  injuries  to  the  head,  and  surgical  operations,  in 
addition  to  the  other  causes  mentioned  on  a  pre^dons  page. 

The  following  differential  diagnosis  is  quoted  with  slight  modifica- 
tions from  the  author's  work  on  "  Surgical  Diagnosis  :" — 


CEREBRAL  THROMBOSIS.  227 

CEREBRAL  EMBOLISM.  CEREBRAL  THROMBOSIS. 

Sex  Affected. 
Most  frequent  in  females.  Equally  frequent  in  the  sexes. 

Onset. 
Sudden.     No  prodromal  symptoms.  Gradual.     Prodromal  symptoms. 

Causes. 
A  history  of  heart-disease  and  the  phys-  Chronic  nephritis, 

ical  evidences  of  a  valvular  lesion  are  usu-  Atheroma, 

ally  to  be  discovered.  Syphilis. 

The  embolus  may  spring,  however,  from  Pachymeningitis. 

an  aneurism  or  a  suppurating  thrombus  and  Hyperinosis. 

be  carried  into  the  circulation  to  the  brain.  Pyemia. 

Pressure  upon  the  veins  or  arteries. 
These  morbid  conditions  all  tend  to  cause 
a  coagulation  of  blood  within  the  vessels 
affected. 

Changes  in  the  Exterior  of  Skull. 

No  changes  in  the  vessels  of  the  exterior  Epistaxis,   oedema   of  the  frontal  veins, 

of  the  skull  are  to  be  detected.  and  exophthalmus  may  occur  if  the  superior 

longitudinal  sinus  is  obliterated. 
The  veins  of  the  neck  are  symmetrical  in  The  external  jugular  veins  may  not  be 

point  of  size.  of  the  same  size — the  one  on  the  obstructed 

side  being  the   smaller — if  the  lateral  sinus 
be  occluded. 

Painful  circumscribed  oedema  behind  the 
ear  may  arise  from  a  thrombus  of  the 
transverse  sinus. 

Suppurative  Changes. 
Suppurative   effects   are   sometimes  pro-  Suppuration  of  the  ear  is  very  common  m 

duced  within  the  brain-substance  (embolic       connection  with  thrombosis  of  the  cerebral 
abscess),  but  seldom  in  distant  parte.  sinuses. 

Abscesses  in  distant  parts  are  liable  to 
form  on  account  of  a  suppurative  disinte- 
gration of  the  thrombi. 

Convulsions. 
Convulsions  are  rare.  Convulsive  attacks  are  common  and  may 

exist  for  months  in  attacks  of  venous  throm- 
bosis. 

Paralysis. 
A  sudden   hemiplegia  usually  occurs —  Comes  on   gradually,   if   at    all,  in  the 

generally  of  the  right  side  venous  variety.      It  may  be  absent. 

Aphasia  exists  in  the  majority  of  cases.  Mavoccursuddenly  in  arterial  thrombosis. 

Aphasia  may  be  developed,  but  is  not 
the  rule. 

Coma. 
The  patient  seldom   loses  consciousness  Profound  coma  often  follows  the  paraly- 

completely  during  the  attack  or  after  it.  sis  or  accompanies  the  attack. 

In  venous  thrombosis  it  may  occur  with- 
out paralysis  having  preceded  it. 

Symptoms  in  Common. 
Both  commonly  affect  the  young  and  early  adult  life. 
Both  may  cause  aphasia,  and  coma. 
Both  may  cause  hemiplegia,  local  paralysis,  convulsions,  .etc. 


228  LECTURES  ON  NERVOUS  DISEASES. 

Prognosis. — This  disc.ise  is  liable  to  prove  fatal  sooner  or  later.  It 
is  possible  that  pyoemia  may  be  induced  by  it,  provided  the  thrombus 
becomes  disintes^rated  by  suppuration.  Emboli  are  thus  formed.  These 
are  subse(iuently  carried  to  other  organs  by  means  of  the  circulation. 
Infarctions  and  embolic  abscesses  of  the  lungs,  liver,  spleen,  kidneys, 
etc.,  may  be  produced  in  this  way.  Softening  of  the  brain  is  a  frequent 
sequel  to  thrombosis.  Death  may  occur  in  a  few  days  if  the  cerebral 
anoi-mia  is  very  profound. 

Treatment. — No  remedial  measures  can  affect  an  existing  thrombus. 
When  the  exciting  cause  can  be  discovered  it  should  be  removed  if  pos- 
sible. The  symptoms  should  be  treated  as  they  develop,  with  the  hope 
that  the  more  serious  complications  of  the  disease  may  not  occur  and  the 
patient  survive  the  attack. 

THROMBOSIS   OF  THE   CEREBRAL  CAPILLARIES. 

The  capillaries  of  the  brain  may  be  extensively  affected  by  small 
thrombi  or  emboli.  This  condition  is  distinct  from  that  comprised 
under  the  common  acceptation  of  the  terms  "  cerebral  embolism"  or 
"cerebral  thrombosis." 

Morbid  Anatomy. — The  microscope  alone  can  detect  the  points  of 
occlusion.  Atheroma  may  be  detected.  The  capillary  vessels  will  l)e 
found  to  contain  pigment-granules,  fatty  masses,  crystals  of  lime-salts, 
etc.     The  larger  vessels  are  not  atheromatous,  nor  are  they  occluded. 

The  brain  may  exhibit  spots  of  softening  or  of  suppuration,  and  the 
cortex  of  the  organ  is  generally  anaemic. 

Etiology. — Pigmentary  embolic  occlusion  of  the  cerebral  capillaries 
may  be  induced  by  malarial  diseases.  Fatty  masses  may  be  formed  at  the 
seat  of  occlusion  as  a  result  of  a  fatty  degeneration  of  the  capillaries, 
or  they  may  be  swept  along  in  the  blood-current  from  distant  foci  of 
fatty  metamorphoses  in  the  bones,  viscera,  heart-cavities,  etc.  Pus-cells 
or  the  white  blood-corpuscles  may  also  occlude  the  cerebral  capillaries, 
chiefly  in  connection  witli  acute  diseases,  causing  a  marked  elevation  of 
temperature,  and  with  leucocythaemia.  Fibrinous  masses  may  be  pres- 
ent in  the  blood-vessels  of  the  brain,  especially  in  rheumatism  and 
inflammatory  diseases;  and  cancerous  material  may  act  as  emboli. 
Finally,  lime-salts  may  be  absorbed  from  diseased  bones  (Virchow)  and 
be  carried  to  the  brain. 

Symptoms. — These  are  vague  and  not  well  understood.  Mental 
disturbances  are  prominent,  such  as  delirium,  loss  of  memory,  loss  of 
emotional  control,  and  hallucinations.  Headache,  nausea,  dizziness, 
trembling  of  the  extremities,  and  paresis  ma}^  develop.  Bastian  advances 
the  view  that  disturbances  of  the  sensorium,  when  occurring  in  acute 


CEKEBEAL   EMBOLISM.  229 

diseases  attendant  with  high  fever,  may  be  due  to  capillary  occlusion 
and  consequent  anaemia  of  the  cerebral  cortex. 

CEEEBEAL   EMBOLISM. 

The  term  "embolus"  is  commonly  used  to  designate  any  foreign 
body  in  a  blood-vessel  which  floats  in  the  blood-current,  or,  in  case  it 
be  stationary,  that  has  been  transported  by  the  blood  from  some  situation 
more  or  less  distant  from  the  seat  of  lodgment.  The  term  "embolism" 
must  not  be  employed  synonymously,  therefore,  with  "thrombus;" 
because  the  latter  term  applies  only  to  a  blood-coagulum  within  a  blood- 
vessel (unhealthy  as  a  rule),  which  has  been  formed  at  the  site  of 
occlusion  of  the  vessel,  and  not  transported  there  by  the  blood. 

Morbid  Anatomy. — The  most  frequent  seat  of  cerebral  embolism  is 
in  the  middle  cerebral  artery  of  the  left  side.  This  is  because  that  arterj' 
forms  the  termination  of  the  most  direct  channel  from  the  heart.  The 
axis  of  the  left  carotid  is  so  situated  in  reference  to  the  curve  of  the 
aorta  as  to  assist  the  passage  of  floating  particles  in  the  blood  into 
its  mouth.  The  internal  carotid  is,  moreover,  the  direct  continuation 
of  the  common  carotid  of  each  side ;  and  the  middle  cerebral  artery 
is  similarly  placed  in  reference  to  the  internal  carotid  after  that  vessel 
enters  the  skull. 

Next  in  point  of  frequency'-  comes  the  right  Sylvian  arter3^  This 
is  because  the  innominate  artery,  although  much  larger  than  the  left 
carotid,  leaves  the  aoi'ta  at  an  angle  opposed  to  the  current  of  blood  in 
that  vessel.  The  middle  cerebral  artery  nourishes,  in  addition  to  other 
convolutions,  the  so-called  "  speech  area"  of  the  cerebral  cortex ;  hence 
plugging  of  the  main  trunk  of  that  vessel  deprives  those  convolutions  of 
blood  that  are  phjsiologically  concerned  in  the  coordinated  movements 
of  articulate  speech.     The  motor  speech  area  is  shown  in  Fig.  5. 

Cerebral  embolism  is  a  frequent  cause  of  extravasation  of  blood, 
because  it  tends  to  induce  infarction.  Again,  it  may  result  in  localized 
softening  of  the  parts  that  are  imperfectly  nourished,  provided  the 
embolus  is  large.  If  the  embolus  is  of  suppurative  origin  the  parts  in 
which  the  nutrition  is  impaired  by  the  embolus  suppurate,  and  a  so-called 
"embolic  abscess"  results. 

An  infarction  is  a  wedge-shaped  spot  of  consolidation  and  discolor- 
ation within  an  organ  dependent  upon  occlusion  of  a  blood-vessel  and 
the  subsequent  rupture  of  neighboring  capillaries.  Whenever  a  vessel 
of  an  organ  becomes  occluded,  the  parts  nourished  by  the  occluded  vessel 
are  deprived  of  blood  until  a  collateral  circulation  is  established.  Now, 
it  is  found  that,  after  such  occlusion,  those  parts  which  are  at  first 
deprived  of  blood  become  subsequeutly  the  seat  of  a  rupture  of  the 
capillary  blood-vessels  (as  the  result  of  an  excessive  pressure  produced  by 


230 


LECTURES   ON   NERVOUS   DISEASES. 


the  collateral  fluxion).  Hence  the  infarction  is  wedge-shaped,  as  a  rule, 
owing  to  the  distribution  of  the  blood-vessels.  Its  apex  (corresponding 
to  the  seat  of  the  plug)  usually  points  toward  the  centre  of  the  organ  in 
which  it  is  detected.  If  the  circulation  is  not  speedil}'  restored,  the  re- 
sult of  defective  nutrition  caused  by  the  embolus  is  evidenced  in  one  of 
three  ways:  either  in  gangrene — if  tlie  part  be  totally  cut  off  from  its 
blood-supply  ;  fatty  degeneration  and  absorption  of  the  embolus  and 
blood-coagula — if  the  nutrition  be  onl}'  partially  cut  off;  or  more  or 
less  extensive  suppuration — if  the  plug  in  the  vessel  be  derived  from  a 
suppurative  focus  or  be  septic  in  its  origin.  We  usually  find,  therefore, 
that  old  infarctions  are  liable  to  appear  pale,  and  to  be  firm  and  incom- 
pletely organized,  j^rovided  that  the  character  of  the  ping  (an  embolus 
or  thrombus)  does  not  create  suppuration  ;  in  which  case  disintegration 


Fig.  76 — A  Diacram  of  an  Embolic  Infarction.  (After  Weber.)  a,  artery  obliterated  by 
an  embolus  (f);  z',  vein  filled  with  a  secondary  thrombus  ((/i);  1,  centreof  the  infarction, 
which  is  becoming  disintegrated  ;  2,  area  ol  extravasation  ol  blood  into  the  tissues  ;  3,  area 
of  collateral  hyperaemia. 


takes  place  rapidly  in  the  centre  of  the  infarction,  and  an  abscess 
results. — "  embolic  abscess." 

The  more  complete  the  obstruction,  the  more  vascular  the  tissue, 
and  the  less  the  vessels  are  supported,  the  greater  is  the  amount  of  in- 
farction and  the  more  rapid  the  softening  and  disintegration  that  ensues. 
The  development  of  "  metastatic  "  or  *'  embolic  abscesses^^  is  one  of  the  dis- 
tinctive pathological  features  of  p3'aimia,  and  no  case  can  be  properl}-  so 
called  when  these  abscesses  are  not  found  after  death. 

Etiology. — For  some  unexplained  reason  the  female  sex  is  more 
frequently  affected  with  cerebral  embolism  than  the  male  sex.  It  is  also 
more  common  in  youth  and  adult  life  than  in  old  age. 

Floating  particles  in  the  circulation  (which  become  emboli  within 
the  vessels  of  the  brain)  may  spring  (1)  from  the  heart-cai'ilies  or  from 
the  mitral  and  aortic  valves;  (2)  from  the  tvalls  of  the  aorta;  (3)  from 


CEREBRAL   EMBOLISM.  231 

the  cavity  of  Home  aneurism;  (4)  from  the  disinlegration  of  some  thrombus 
in  other  parts  of  the  body  (the  loosened  particles  being  swept  into  the 
circulation);  (5)  from  particles  of  connective-tissue  growths  which  affect 
the  vascular  system;  (6)  from  chalky  concretions;  and  (7)  from  foreign 
bodies  introduced  into  the  circulation  from  without. 

Affections  of  the  heart,  especially  endocarditis,  are  liable  to  be 
followed  b^'^  attacks  of  cerebral  embolism.  Aneurisms  of  the  aorta  or 
carotids  are  the  next  most  common  source  of  emboli.  Pyaemia  or  sup- 
purative phlebitis  may  induce  emboli  by  disintegration  of  blood-clots. 
Oppolzer  records  a  case  where  a  syphilitic  gumma  of  the  cardiac  wall 
broke  through  the  sinus  of  Valsalva  and  caused  embolism.  A  rheumatic 
history  should  point  3'ou  to  an  examination  of  the  heart  for  valvular 
defect.  Cardiac  thi'ombosis  has  been  known  to  excite  embolism.  Car- 
cinoma, tuberculosis,  and  empyema  may  also  act  as  etiological  factors 
of  this  condition. 

The  size  and  number  of  the  floating  particles  modify  the  seat  and 
number  of  the  emboli.  If  small,  the  capillaries  of  the  brain  alone  may 
be  occluded;  if  large,  one  or  more  of  the  main  trunks  are  liable  to  be 
plugged,  and  a  much  larger  area  of  brain-substance  is  thus  deprived 
of  blood.  Not  infrequently  many  vessels  are  simultaneously^  obstructed 
at  the  same  time.  Sometimes  all  the  main  vessels  on  one  side,  and  at 
other  times  vessels  of  both  sides,  are  more  or  less  occluded. 

Symptoms. — The  common  effects  of  occlusion  of  a  large  trunk  are 
sudden  aphasia  and  hemiplegia  (usually  of  the  right  side  of  the  body). 
Wlien  the  capillaries  alone  are  involved  and  the  main  trunks  escape,  the 
effects  and  symptoms  vary  with  the  seat  of  the  embolus,  because  only 
certain  limited  portions  of  the  brain  are  then  deprived  of  their  nutrition. 
The  collateral  circulation  of  the  bx'ain  takes  place  almost  entirely  through 
the  larger  arteries.  It  forms,  therefore,  an  exception  to  the  other 
tissues. 

There  are  usually  no  premonitory  symptoms  that  indicate  the  ap- 
proach of  the  attack.  The  patient  does  not  (as  a  rule,  at  least)  lose 
consciousness;  although  there  may  be  a  slight  confusion  of  the  mental 
faculties  for  a  time.  In  some  instances,  however,  coma  accompanies  the 
attack  of  paralysis.  Although  so  eminent  an  authority  as  Nothnagel 
states  that  embolic  attacks  are,  as  a  rule,  accompanied  by  profound  coma, 
m3'  experience  does  not  confirm  that  view.  I  regard  such  cases  as  ex- 
ceptions to  the  general  history  of  embolism ;  although  it  cannot  be  denied 
that  they  are  frequent  exceptions.  Even  then  the  patient  recovers  con- 
sciousness gradually  within  a  few  hours.  Ptosis,  a  squint  of  one  eye, 
and  even  blindness  have  been  known  to  accompany  the  attack;  but  these 
complications  are  rather  infrequent.  In  still  rarer  cases,  paralysis  may 
not  be  developed  in  any  part  of  the  body.     The  paralysis  tends  to  exhibit 


232  LECTURES   ON   NERVOUS   DISEASES. 

a  marked  improvement  within  forty-eight  hours,  if  collateral  circulation 
is  established. 

The  difficulty  in  speech  which  commonly  results  from  cerebral  em- 
bolism is  not,  as  a  rule,  due  to  paralysis  of  the  hypoglossal  nerve,  as  it 
is  present  in  cases  where  the  movements  of  the  tongue  are  normal.  It  is 
to  be  attributed  to  sudden  anaemia  of  the  "  speech  centre  "  of  Broca.  This 
is  situated  chiefly  in  the  base  of  the  third  frontal  convolution  and  the 
adjacent  "ishind  of  Reil."  There  are  cases  reported  where  both  the 
hypoglossal  and  facial  nerves  have  been  simultaneouslj'  paralyzed  as  a 
result  of  embolism,  but  they  are  exceptional. 

The  pupils  are  not  often  affected  in  embolism.  The  pulse  is  com- 
monl}'  small  in  volume  and  somewhat  weak.  The  temperature  may  fall 
slightl^^  below  the  normal  point.  A  valvular  heart-lesion  will  frequently 
be  discovered.  Vegetations  upon  the  aortic  and  mitral  valves  are  a 
prolific  source  of  emboli.  The  arteries  of  the  retina  are  frequently  en- 
larged at  the  onset  of  the  attack,  because  the  ophthalmic  arteries  arise 
below  the  middle  cerebral. 

Emboli  are  so  rareh'  conveyed  to  the  brain  by  means  of  the  ver- 
tebral arteries  that  the  symptoms  produced  by  occlusion  of  the  branches 
supplied  by  that  vessel  may  be  clinically  disregarded. 

Aneurism  of  the  arch  of  the  aorta,  or  of  the  innominate  and  carotid 
arteries  may  prove  an  exciting  cause  of  cerebral  embolism.  In  these 
cases,  portions  of  the  laminated  fibrin  or  blood-coagulum  which  line  the 
interior  of  these  sacs  become  detached  and  are  swept  into  the  circulation. 
It  is  well  to  remember  this  fact,  as  sj^mptoms  referable  to  aneurismal 
tumor  may  occasionally  coexist  with  those  produced  by  the  cerebral 
embolus. 

Convulsions  may  accompany  the  development  of  cerebral  embolism. 
The  form  of  convulsion  ma}^  be  of  the  tj-pical  epileptic  attack,  or  it 
may  be  only  a  slight  twitching  of  the  muscles,  one  of  the  limbs,  or  the 
face.  The  convulsive  attack  may  precede  the  paralysis,  if  of  the  mild 
type.  With  bilateral  embolism,  convulsions  are  rarely  absent.  They 
are  due  to  the  extensive  anaemia  that  is  suddenly  induced.  Transient 
delirium  may  accom])any  an  attack  of  embolism. 

Differential  Diagnosis. — From  cerebral  ajwplexy  the  diagnosis  is 
often  difficult.  Embolism  is  to  be  diagnosed  chiefly  b}^  the  absence  of 
profound  coma  (although  there  are  frequent  exceptions  to  this  rule),  the 
absence  of  prenionitor}'  symptoms,  the  fact  that  any  age  may  be  attacked, 
the  frequent  coexistence  of  a  valvular  lesion  of  the  heart,  or  possibly 
of  an  aneurism  of  the  aorta  or  the  carotid  artery,  the  predisposition  of 
the  right  side  of  the  body  to  paralysis,  the  simultaneous  development 
of  aphasia,  and  the  slow  improvement  in  the  paralysis,  provided  it  re- 
mains well  established  on  the  fourth  day  after  the  attack. 


APHA8IA.  23»^ 

From  cerebral  llirombosis  the  clhignosis  is  less  dillicult.  The  sudden- 
ness of  the  onset,  the  rapid  development  of  aphusia  and  right  hemiplegia, 
the  absence  of  prodromal  symptoms,  the  presence  of  valvular  defect  of 
the  heart,  the  absence  of  atheromatous  changes  in  the  vessels,  or  of  any 
of  the  well-known  exciting  causes  of  thrombosis,  the  retention  of  con- 
sciousness (more  or  less  complete)  during  the  attack  of  paral3'sis,  and 
the  absence  of  suppuration  of  the  ear,  epistaxis,  circumscribed  oedema 
of  the  frontal  or  mastoid  regions,  are  the  chief  diagnostic  ]ioints  of 
embolism      These  points  are  contrasted  on  page  227. 

Prognosis. — Tlie  danger  of  rapid  cerebral  softening  ami  possibly'  of 
abscess  rendei-s  the  prognosis  somewhat  grave  as  regards  complete 
recovery,  provided  the  paralysis  does  not  disappear  to  a  great  extent 
within  forty-eight  hours  after  the  attack.  If  a  large  vessel  be  occluded, 
collateral  circulation  may  be  established  rapidh*.  The  persistence  of 
head  symptoms  is  another  omen  of  evil,  import.  It  must  not  be  for- 
gotten that  the  exciting  cause  remains  and  subsequent  attacks  may  be 
exi)ected. 

Treatment. — The  symptoms  must  be  treated  as  they  arise.  The 
patient  must  be  kept  quiet,  and  all  mental  activity  aA^oided  for  several 
weeks.  Stimulants  and  digitalis  are  only  indicated  when  collapse 
threatens.  The  faradic  current  will  usuall}'  tend  to  i^nrtiall}^  relieve  the 
paralysis,  in  case  it  persists  after  the  third  week. 

APHASIA. 

This  subject  has  been  discussed  at  some  length  in  a  previous  chapter 
(p.  66).  The  reader  is  referred  to  the  remarks  already  made  rela- 
tive to  the  significance  of  this  symptom,  and  its  bearing  upon  cerebral 
localization. 

Motor  Aphasia  is  one  ot  the  most  common  symptoms  of  cerebral 
embolism,  although  it  occurs  often  in  connection  with  anaiinia  from  other 
causes,  and  also  from  lesions  of  a  destructive  character.  It  seems  proper 
therefore  to  consider  its  clinical  significance  again  in  this  connection. 
Too  gi'cat  stress  cannot  be  laid  ujjon  the  fact  that  motor  aphasia  is  not 
pathognomonic  of  embolism.  It  ma^-  occur  in  connection  with  cerebral 
hemorrhage  and  many  other  diseases  of  the  brain. 

It  should  be  remembered  also  that  ai)h:isia  may  be  due  either  to  an 
inability  to  i)ropcrly  coordinate  the  muscles  of  articulation  (which  are 
governed  to  a  marked  degree  by  the  centre  of  Broca),  or  to  a  loss  of 
memory  of  articulate  sounds  or  their  symbols.  Should  the  meaning  of 
.spoken  language  be  lost,  the  lesion  is  probably  situated  in  the  first 
temporal  convolution,  and  not  in  the  centre  of  Broca ;  provided  the 
patient  can  articulate  perfectly,  as  can  be  determined  by  having  the 
patient  repeat  single  test-words,  and  in  other  ways.     (See  page  64.) 


234  LECTUliES    ON    NEKVOUS    DISEASES. 

Among  the  npliasic-syiuplom  group  may  be  mentioned  the  coiKlitions 
known  as  "aphasia,"  "alexia,"  "amimia,"  "apraxia,"  "  asymbolia," 
"agraphia,"  and  "  })araphasia."  Thus,  disturbances  of  speech  {true 
aphakia)  \n\xy  be  associated  with  an  inability  to  read  (alexia)^  to  make 
appropriate  gestures  {amimia)^  to  recognize  objects  in  common  use 
(aprax-ia),  to  sign  the  name  (asynibolia),  to  write  or  coi)y  {agraphia)^ 
and  to  properly  select  w(jrds  {paraphasia). 

The  term  "  apraxia  "  has  be(Mi  employed  by  some  authors  to  cover 
a  class  of  cases  where  by  disease  of  the  cortical  centres  of  sight  the 
patient  has  been  rendered  psychically  blind,  not  to  the  meaning  of  words, 
but  to  the  most  familiar  objects  and  their  uses.  Such  ])atients,  after 
being  disrobed  and  having  their  clothing  returned  to  them,  have  been 
known  to  require  instruction  as  to  what  uses  to  put  each  garment  to. 
The  most  common  objects  about  them  are  apt  to  be  regarded  as  things 
unknown  by  such  subjects. 

The  lack  of  ])<)wer  to  express  the  psychical  states  by  means  of 
gestures  has  been  designated  '•'•amimia.''''  The  power  of  appi'eciating  the 
meaning  of  gestures  made  by  others  may  coexist  with  the  loss  of  power 
on  the  part  of  the  i)atient  to  personallj'-  execute  api>ro]jriate  mimic 
interpretations  of  thought. 

Whenever  motor  aphasia  is  clearly  dependent  upon  cerebral  embo- 
lism or  general  cerebral  anaemia,  efforts  should  be  made  to  relieve  the 
vascular  disturbance  (as  far  as  is  possible),  and  to  treat  the  coexisting 
symptoms.  Such  steps  will  be  discussed  in  connection  with  cerebral 
ansEmia. 

Clinicall}',  however,  we  often  encounter  motor  or  sensory  aphasia 
in  connection  with  circumscribed  lesions,  such  as  depressed  bone,  menin- 
geal or  cerebral  hemorrhage,  suppuration  after  an  injury  to  the  skull, 
cerebral  softening,  tumors,  etc.,  as  well  as  a  symptom  of  embolism. 

Under  such  circumstances  the  question  of  mechanical  relief  by  the 
trephine  has  to  be  considered. 

There  is  a  safe  rule  to  follow  whenever  the  use  of  the  trephine  is 
suggested,  viz.,  ??euer  ^0  empjloi/  it  ivhen  xe>i,-ioru  paralysis  coexists  with 
motor  parali/sis^or  when  the  motor  pai-ali/sis  exi)^ts  on  the  side  of  the  l)ody 
corresponding  to  the  probable  seat  of  th4  cerebral  lesion. 

The  reasons  for  this  rule  arc  self-evident.  The  coexistence  of  motor 
and  sensory  i)aralysis  indicates  a  lesion  that  is  either  too  extensive  or 
deeply  seated  (although  it  may  possibly  be  cortittal  in  character)  to  be 
benefited  by  the  removal  of  a  small  button  of  bone.  Again,  the  develop- 
ment of  paralysis  upon  the  same  side  as  a  cerebral  lesion  justifies  a 
doubt,  to  say  the  least,  regarding  the  hemisphere  of  the  brain  which  has 
been  injured. 

Those  cases  known  as  word-deafness  and  word-blindness,  where  the 


APHASIA. 


235 


nieniorv  of  spoken  words  or  of  written  characters  has  been  effaced  by  a 
cerebral  lesion,  are  now  better  understood  than  in  the  past.  We  have 
reason  to  believe  that  the  memories  of  sounds  are  stored  in  the  cells  of 
the  first  temporal  convolutions,  and  those  of  sight  in  those  of  the  occipi- 
tal lobes.  We  also  know  that  after  a  lesion  of  these  gyri  has  effaced  past 
memories  new  ones  may  be  often  acquired  and  retained,  provided  that 
all  of  the  cells  of  the  affected  gyrus  are  not  actually  destroyed.  Hence 
we  have  come  to  learn  that  patients  atllicted  with  aphasia  of  the  amnesic 
type  (p.  63)  can  be  slowly  taxight  in  some  cases  the  meaning  of  sounds, 
and  cases  of  word-blindness  those  of  symbols,  in  spite  of  the  fact  that 


THE  SO-CALLED 

'SPEECH  TRACT' 


•-^JJUCLEI  OF  ORIGIN 

OF  fJERVES 
''iMPWYED  IN  SPEECH 


KiG.  77. — A  Diagram  Designed  by  the  Author  to  Illustrate  the  Mechanism  of  tme 
Apparatus  Required  in  Speech. — The  reader  must  not  regard  this  diagram  as  intended 
to  accurately  portray  the  anatomical  relations  of  the  various  centres  and  tracts  to  each  other. 
The  physiological  interpretation  of  this  diagram  has  been  given  on  page  67. 

the  memories  of  such  have  been  mechanically  effaced.  The  cortical  cells 
associated  with  the  auditory  nerves  or  with  the  eyes  must  be  developed 
anew  in  respect  to  their  functional  attainments,  as  if  the  patient  were  an 
infjxnt.  Words  must  be  repeated  again  and  again,  until  the  patient  can 
retain  them  in  memory  and  pronounce  them  properly,  in  case  of"  word- 
deafness,"  and  after  the  development  of  "  word-blindness  "  the  patient 
must  sometimes  be  taught  the  letters  and  numerals  in  the  same  way  as 
a  child  is  instructed.  The  tests  for  these  conditions  have  been  given  in 
the  preceding  section  (p.  183). 


236  LECTURES    OX    NERVOUS   DISEASES. 

In  esises  when*  word-di'd/tiess  is  suspected  to  exist  it  is  well  to  test 
the  patient  by  instriietinir  him  to  do  certain  simph'  thintys,  such,  for 
example,  as  piittiny-  out  the  tonuiie,  poiiitinji;  to  selected  olyects  in  the 
room,  shakiiiii  liands,  passiuLj  common  ol)jects  to  some  third  party,  etc. 
it  is  particularly  important  that  no  sign  or  gesture  should  be  employed 
whiK'  making  such  tests  as  will  serve  to  aid  the  patient  in  discerning 
the  meaning  of  any  of  tlic  requests  made  as  a  means  of  determining 
the  integrity  of  the  cortical  centres  of  hearing. 

Umboiiam  of  the  left  middle  cerebral  artery  is  perlia])s  the  most 
frequent  cause  of  true  motor  aphasia,  because  the  same  vessels  which 
nourish  the  motor  speech-centre  supply  also  most  of  the  motor  centres 
in  the  two  central  convolutions.  A  right  hemiplegia  is  commonly 
observed  in  connection  with  aphasia  (when  due  to  embolism). 

Agruph  ia,  like  ai)hasia ,  may  be  of  the  ataxic  or  amnesic  types.  When- 
ever the  sight  and  hearing  centres  are  impaired,  copying  from  sight  or 
dictation  will  be  rendered  impossible,  because  centres  which  control  the 
muscles  em])loyed  in  writing  lack  the  necessary  stimulus  to  perform  such 
coordinated  movements. 

When  the  coordinating  centre  of  the  muscles  of  speech  is  perma- 
nently impaired  by  a  lesion  of  the  vessels  or  brain-tissue,  the  prospect 
of  a  return  of  the  normal  power  of  articulation  is  not,  in  my  experience, 
encouraging,  although  great  improvement  may  sometimes  occur  (pos- 
sibly by  the  aid  of  the  homologous  centre  in  the  uninjured  hemisphere). 

The  guides  that  are  emploj^ed  to-day  in  trephining  for  the  special 
centres  of  the  cerebral  cortex  have  been  given  elsewhere  (p.  49). 

My  friend  and  late  colleague  Prof.  Wm.  11.  Thonqjson,  of  New- 
York,  has  lately  published  a  very  interesting  case  of  word-blindness 
which  came  under  his  personal  observation.  1  take  the  liberty  of 
quoting  his  record  of  this  case  in  full : — 

"On  May  1,  1884.  I  was  called  to  one  of  ray  stated  patients,  a  lady  of  about  sixtj- 
years  of  age.  whom  I  found  naturally  anxious  about  a  peculiar  experience  which  had 
befallen  her.  The  previous  afternoon  she  liad  taken  a  long  ride  in  her  carriage  to  Green- 
wood Cemetery,  to  visit  the  grave  of  her  only  son,  who  died  three  years  before,  of  phthisis. 
She  said  that  she  had  enjoyed  the  nde.  and  did  not  feel  particularly  fatigued  by  it,  but  on 
returning  home  began  to  experience  a  sensation  of  unusual  weariness.  She  exerted  her- 
self, however,  then,  before  going  down  to  dinner,  to  write  an  advertisement  to  come  out  in 
the  morning  paper  for  a  servant-girl.  She  was  surprised,  however,  to  find  that  for  some 
unaccountable  reason  she  could  not  word  the  advertisement  to  suit  her,  and  after  tearing 
up  some  five  or  six  such  written  attempts  she  was  obliged  to  ask  her  sister  to  write  the 
notice  for  her.  Soon  afterward,  while  at  the  dinner-table,  a  severe  pain  set  in  at  the 
upper  portion  of  the  left  temple,  which  continued  to  increase  until  it  obliged  her  to  retire 
to  her  room,  and  not  long  afterward,  to  bed.  This  pain  persisted  through  the  night,  but 
did  not  prevent  her  from  having  a  fair  amount  of  sleep.  She  rose  at  her  customary  hour 
in  the  morning,  and  but  for  the  persistence  of  the  same  pain,  though  in  less  degree  than  on 
thi'  rv.Miing  before,  she  would  not  have  noticed  anything  unusual  about  herself,  had  it  not 


I 


APHASIA.  237 

been  for  the  arrival,  soon  aftei  breakfast,  of  an  applicant  in  answer  to  her  advertisement. 
Upon  the  girl  handing  her  some  written  recommendations  the  lady  found  herself  unable 
to  make  anything  out  of  either  one  of  them,  and  had  to  call  her  sister  in,  who  then  read 
them  without  difficulty.  Soon  another  girl  came  in,  and  my  patient  experienced  just  the 
same  difficulty  in  attempting  to  read  her  references.  She  said  that  her  first  thought  was 
that  something  was  wrong  with  her  eyes,  but  on  looking  around  the  room  and  inspecting 
a  number  of  small  articles  minutely  she  was  satisfied  that  she  could  see  and  distinguish 
objects  as  well  as  ever.  The  moment,  however,  that  she  turned  to  the  writing,  while  she 
knew  that  she  could  see  the  written  characters  as  well  as  she  could  see  worsted  work,  yet 
not  a  single  letter  conveyed  any  idea  to  her  mind  of  its  character  or  meaning.  She  there- 
upon took  up  a  newspaper,  and  at  once  recognized  that  something  peculiar  had  happened 
to  her,  for  she  was  totally  unable  to  read  a  word  in  it.  The  separate  letters  could  be  seen, 
but  an  indescribable  blur,  as  she  thought,  rendered  it  all  indistinguishable ;  whereupon  I 
was  sent  for  to  explain  the  difficulty. 

"  I  was  much  interested,  of  course,  in  the  patient's  story,  for  nothing  could  have  been 
better  described  or  expressed  in  words.  There  was  neither  hesitancy  nor  thickness  in  her 
articulation,  nor  confusion  in  diction  or  thought,  but,  on  the  contrary,  she  detailed  her  case 
with  a  peculiarly  good  choice  of  terms.  '  What  is  it,  doctor,  that  makes  that  newspaper  so 
illegible  to  me?  I  see  that  there  are  words  there,  but  I  am  wholly  unable  to  tell  what 
they  are,'  were  some  of  her  remarks.  At  first  I  directed  my  questions  so  as  to  avoid, 
increasing  her  alarm  and  excitement,  and  in  time  found  that  she  had  not  experienced, 
another  symptom  except  the  above-mentioned  pain  and  her  inability  to  read  or  write.. 
She  felt  no  numbness  or  tingling,  either  in  the  face  or  extremities,  nor  any  loss  of  power, 
her  grasp  being  the  same  as  usual  in  each  hand,  while  no  difference  was  perceptible  to  her 
between  either  of  the  lower  extremities  in  walking.  The  use  of  the  hands  for  sewing, 
buttoning,  or  tying,  and  for  holding  a  pencil  for  writing  seemed  as  good  as  ever.  There 
was  no  difference  observable  in  the  vision  of  the  two  eyes, — no  specks,  nor  mists,  nor 
colored  images;  no  marked  difference  in  hearing  on  either  side,  nor  any  other  symptoms- 
referable  to  the  ears;  and  there  was  no  dizziness  whatever.  The  face  showed  no  distor- 
tion, either  when  the  patient  was  speaking  or  laughing.  Examination  of  the  radials 
showed  them  to  be  hard  and  tortuous,  and  the  pulse  was  of  high  tension  and  slightly 
quickened.  I  may  remark  here  that  a  brother  of  the  patient,  a  few  years  her  senior,  had 
a  slight  hemiplegia  attack,  with  aphasia,  some  seven  years  ago,  from  which,  however,  he 
has  quite  recovered. 

"  At  ray  first  visit  I  was  soon  obliged  to  desist  from  experimenting  with  my  patient's 
inability  to  recognize  written  or  printed  words  or  figures;  for  the  plainer  this  strange  dis- 
abilty  became  to  her  by  my  tests  the  more  she  was  inclined  to  become  distressed  by  it 
and  to  press  for  an  explanation,  so  that  I  feared  the  effects  of  excitement  upon  her  cere- 
bral circulation.  At  my  visit  the  next  day  the  pain  in  the  temple  still  persisted,  and  was 
uniformly  described  as  running  along  a  line  which  corresponded  to  the  temporo-parietal 
suture.  Some  days  afterward  it  was  noticeable  that  she  occasionally  miscalled  words,  of 
which,  however,  she  immediately  corrected  herself.  On  cautiously  testing  her  again,  I 
found  that  her  word-blindness  at  the  end  of  the  week  was  complete.  The  largest  letters, 
like  the  heading  of  the  New  York  Herald,  and  figures  were  as  unrecognized  by  her,  when 
seyiarately  pointed  out,  as  the  smallest.  With  the  exception,  however,  just  mentioned,  her 
spoken  language  was  that  of  a  well-educated  woman  who  had  learned  to  express  herself 
fluently  and  well. 

"  Her  recovery  from  this  condition  began  in  about  two  weeks  and  progressed  gradu- 
ally until  in  three  months  she  could  both  read  and  write,  especially  the  latter,  with 
tolerable  facility.     When  she  began  to  write  again,  however,  it  was  in  a  very  small  hand ; 


238  LECTURES   ON   NERVOUS   DISEASES. 

but  in  time  she  quite  recovered  her  ordinary  handwriting.  Since  then  she  has  shown 
httle  or  no  change,  except  a  marked  increase  of  restlessness  and  imj>atience.  She  now 
writes  all  her  own  letters,  but  says  that,  whereas  she  used  to  be  a  good  correspondent,  the 
task  of  answering  letters  has  become  very  irksome.  Reading,  however,  she  finds  more 
difficult  than  writing,  for  she  can  read  aloud  only  slowly ;  while  reading  to  herself,  she 
says,  soon  fatigues  her." 

Differential  Diagnosis. — The  following  table  is  quoted  -witli  some 
moditications  in  this  connection  from  the  third  edition  of  the  author's 
work  upon  ''  Surgical  Diagnosis  ": — 

GLOSSO-LABIO-LARYNGEAL 
APHASIA.  PARALYSIS. 

(Duchesne's  Disease.) 
Eaely  Symptoms. 

The  loss  of  speech  is  usually  sudden  and  Patient  notices  a  slight  impediment  in 

only  partially  complete.  speech  early  in  the  disease,  or  a  tendency 

The   lips  are  under  perfect  control   and       in  the  lips  to  separate  and  remain  apart, 
do  not  tend  to  separate. 

Deglutition. 

Swallowing  k  not  interfered  with.  Swallowing  is  imperfectly  performed  later 

on  in  the  disease. 

The  palate  becomes  affected,  and  attempts 
at  swallowing  induce  symptoms  of  strangu- 
lation. 

Face. 
The  face  is  normal  in  expression.  Saliva  dribbles  constantly  from  the  mouth, 

in  the  advanced  stages  of  the  disease ;  and 
the  face  is  altered  by  the  attitude  of  the  jaw 
and  the  separation  of  the  lips. 

Speech. 

In  the  ataxic  or  "  motor  "  variety,  speech  The  lingual  and  dental  consonants  are 

is  impaired  in  a  variety  of  ways  (page  64).  first  pronounced  with  difficulty,  and,  later 

In  the  amnesic  or  "sensory"  variety,  some  on  the  labials, 
form  of  memory  of  words  or  symbols  is  lobt. 

^Mastication. 

Mastication  is  performed  as  in  health.  The  food  accumulates  in  the  cheek  during 

eating,  as  the  tongue  cannot  control  the 
bolus  properly. 

Respiration. 

Respiration  is  not  afi'ected.  Respiration  becomes  impaired,  from  paral- 

ysis of  the  muscles  necessary  to  that  act. 
The  patient  often  cannot  cough  or  breathe 
deeply. 

Voice. 
The  voice  is  normal.  Phonation  becomes  impossible  when  the 

larynx  is  paralyzed. 

Atrophic  Changes. 

No  atrophic   changes  in   muscles   occur  As  the  disease  tends  to  extend  into  the 

throughout  the  disease.  spinal  cord  and  involve  the  cells  of  its  gray 

matter,  symptoms  of  muscular  atrophy  de- 
velop. 


HYPEK^MIA   OF   THE   BRAIN   AND   ITS    COVERINGS.  239 

Motor  Paralysis. 

The  rir/ht  side  of  the  body  is  usually  ren-  Motor   paralysis   is  not  developed  as  a 

dered  hemiplegic,  when  the  aphasia  is  of  result  of  the  spinal  changes.  The  patient 
the  motor  variety.  This  is  especially  true  becomes  unable  to  walk,  however,  as  a 
if  an  embolus  exists  as  its  cause.  result  of  general  debility  and  the  atrophy 

of  the  muscles. 

Memory. 

The  memory  may  be  impaired,  in  the  am-  The  memory  of  words  is  intact,  but  the 

nesic  variety,  in  respect  to  words,  figures,       ability  to  use  the  tongue  and  lips  interferes 
foreign  tongues,  familiar  objects  and  their       with  articulate  speech. 
uses,  gestures,  etc. 

Dementia. 

Dementia  seldom,  if  ever,  occurs.  In  exceptional  cases,  dementia  develops 

late  in  the  disease. 

Symptoms  in  Common. 

Both  may  be  associated  with  impairment  of  the  normal  use  of  the  tongue. 
Both  may  be  associated  with  delects  of  speech. 

Prognosis  and  Treatment. — The  duration,  course,  and  severity  of 
the  abnormal  conditions  described  under  the  general  head  of  aphasia 
depend  to  a  great  extent  upon  the  exciting  cause  and  its  exact  seat.  In 
the  first  section  of  this  work,  the  localization  of  the  lesion  and  the  com- 
plications most  frequently  encountered  in  connection  with  aphasia  have 
been  quite  fully  discussed.     To  these  pages  the  reader  is  referred. 

The  treatment  of  the  various  lesions  which  may  induce  aphasia 
will  be  discussed  later,  under  the  heads  of  cerebral  hemorrhage,  tumors, 
softening,  abscess,  etc.  Some  points  relative  to  the  treatment  of  cere- 
bral embolism  and  thrombosis  have  already  been  given. 

HYPEREMIA   OF   THE   BRAIN   AND   ITS   COVERINGS. 

Contrary  to  opinions  of  the  past,*  it  is  now  quite  well  determined 
that  the  quantity  of  blood  within  the  cavity  of  the  skull  may  admit  of 
variation  and  be  increased  under  certain  circumstances  to  an  abnormal 
extent,  constituting  the  condition  known  as  cerebral  hyperfemia."}* 

Two  forms  are  commonly  recognized, — the  active  and  j^assive.  Both 
may  be  general  or  localized. 

*  The  experiments  of  Kellie  led  him  to  deny  that  tlie  cerebral  circulation  could  be 
affected  by  bleeding,  the  ligation  of  veins,  etc. 

f  Burrows,  Donders,  Kussmaul  and  Tenner,  Jolly,  Leyden,  Ackermann,  and  Ermann 
have  demonstrated  that  the  view  of  Kellie  was  untenable. 

The  functions  of  the  cerebrospinal  fluid  were  imperfectly  understood  until  Magendie, 
Longet,  and  Ecker  brought  them  to  light.  The  perivascular  lym2)h  spaces  unquestionably 
assist  also  in  the  imperfectly  understood  mechanism  by  wliicli  the  cerebral  circulation  is 
regulated.  Maingien  believes  that  the  thyroid  gland  plays  an  important  part  in  preventing 
over-distention  of  the  cerebral  vessels, — a  conclusion  that  is  sustained  by  as  high  an 
authority  as  Guyon.  The  thyroid  lobes  become  turgid  and  swollen  during  excessive  mus- 
cular exercise,  and  overcomes  (by  compressing  the  carotid  arteries)  the  danger  of  venous 
congestion  of  the  brain. 


240  LECTUKES    ON    NERVOUS  DISEASES. 

In  the  active  variety,  the  t)h)od-vessels  are  dilated  and  (although  the 
amount  of  blood  is  proportionately'  increased)  the  current  is  very  rapid. 
In  the  pa)<sive  form,  the  blood-vessels  are  dilated  and  the  amount  of  blood 
is  also  proportionately  increased,  but  the  current  is  slower  than  normal. 

The  term  "cerebral  congestion"  is  properly  applied  to  the  latter 
variety  only,  in  spite  of  tho  fact  that  authorities  of  note  sometimes 
employ  it  when  speaking  of  both  forms. 

Some  neurologists  have  attempted  to  classify  cerebral  hypera?mia  on 
a  basis  of  its  symptomatology.  Andral  speaks  of  eight  varieties,  and 
Hammond  of  six.  These  have  been  designated  by  the  terms  "  apoplectic," 
"paralytic,"  "convulsive,"  "maniacal,"  etc.,  in  accord  with  the  most 
prominent  of  the  symptoms  exhibited. 

Morbid  Anatomy. — Great  variations  in  the  intensit}^  of  cerebral  and 
meningeal  hyperemia  are  observed. 

If  the  condition  be  of  the  general  variety,  in  contradistinction  to 
local  hyperjemia,  the  vessels  will  be  found  to  be  engorged  and  the  mem- 
branes altered  in  their  color.  Some  of  the  cerebral  convolutions  may  be 
slightly  compressed  and  flattened.  Finally,  hemorrhagic  points  may  be 
detected  both  in  the  gray  and  white  substance  of  the  brain  on  section. 
In  some  cases,  coagula  of  blood  may  be  detected  in  both  the  arteries  and 
sinuses. 

Chronic  hyperaemia  is  recognized  chiefly  b}^  a  thickening  and  opacity 
of  the  membranes  and  marked  dilatation  of  the  vessels.  The  cerebellar 
meninges  are  commonly  more  vascular  than  those  of  the  anterior  por- 
tions of  the  brain.  In  some  insane  patients,  the  cortex  may  assume  a 
brownish  and  pigmented  condition. 

Localized  areas  of  hyperaemia  are  occasionally  observed.  These 
sometimes  coexist  with  embolism  or  thrombosis.  The  basal  ganglia 
(corpus  striatum  and  optic  thalamus)  occasionally  exhibit  isolated  con- 
gestions. 

It  is  not  uncommon  to  meet  an  increase  in  the  subarachnoidean  fluid 
and  distension  of  the  choroid  plexuses,  in  connection  with  cerebral  con- 
gestion. Moreover,  particles  of  hsematin  ma}^  often  be  found  in  contact 
with  the  blood-vessels,  and  miliary  aneurisms  are  liable  to  be  found. 

Etiology.— In  a  general  way  it  may  be  stated  that  the  so-called 
"active"  form  of  cerebral  hyperaemia  is  dependent  upon  any  cause  that 
tends  to  increase  the  arterial  supply  of  the  brain  or  its  coverings  without 
Interfering  with  the  venous  return  from  the  vessels  within  the  skull,  and 
that  the  "passive'  variety  results  from  defective  venous  return,  irre- 
spective of  the  arterial  supply  This  axiom  is  not  strictly  true  in  all 
cases,  because  the  passive  form  ma}-  develop  as  a  secondary  result  of  the 
active;  but  it  will  hold  good  in  the  majority  of  cases  and  i:)rove  of  assist- 
ance often  in  diagnosis. 


HYPEREMIA    OF    THE   BRAIN    AND    ITS    COVERINGS.  241 

The  Active  Variety  (cerebral  Jluxion). — A  heated  atmosphere  is 
often  a  factor  in  tlie  development  of  the  actiA'e  variety.  The  passiA'e 
form,  on  the  other  hand,  is  more  frequent  in  extremely  cold  weather,  as 
sustained  by  the  observations  of  Andral  and  Hammond ;  but  cold  may 
induce  either  variety. 

An  increased  hearfn  action  (as  in  the  case  of  fevers,  mental  excite- 
ment, severe  physical  exertion,  and  cardiac  hypertrophy)  may  be  an 
important  factor  in  producing  the  active  or  ''fluxionary  "  type. 

Again,  i\w  cerebral  arteries  may  poasesi^  weak  walls;  so  that  they 
yield  to  an  increased  pressure  of  blood  sooner  than  the  rest  of  the 
arterial  system,  thus  causing  what  is  termed  a  ''rush  of  blood  to  the 
head." 

As  a  fourth  factor,  increased  lateral  pressure  within  the  carotids 
may  be  mentioned.  This  occurs  in  connection  with  constriction  of  the 
thoracic  or  abdominal  aorta,  or  compression  of  the  abdominal  aorta  by 
distended  intestines  or  abdominal  tumors,  and  of  the  thoracic  portion 
of  that  A^essel  b}'  mediastinal  growths,  emph3'sema,  etc.  The  effect  of 
cold  upon  the  surface  of  the  body,  which  checks  the  determination  of 
blood  to  the  skin  and  drives  an  excess  of  blood  to  the  viscera,  may  also 
be  evidenced  in  the  cerebral  vessels. 

Again,  vaso-niotor  paralysis  may  induce  active  cerebral  hyperaemia. 
An  excess  of  alcohol,  indulgence  in  some  drugs,  malarial  poisoning,  pro. 
longed  mental  lalxjr,  and  emotional  excitement  may  also  lead  to  this 
condition.  Oi)ium-eaters  and  drunkards  have  chronic  cerebral  hyper- 
emia, as  a  rule. 

Finally,  cerebral  atrophy  may  possibl}'  be  associated  with  that  form 
of  cerebral  hyperaimia  which  is  occasionally  encountered  during  con- 
valescence from  severe  attacks  of  illness. 

The  Passive  Yakiety  {cerebral  congestion)  must  of  necessity  depend 
to  a  great  extent  upon  causes  that  interfere  with  the  return  of  blood  from 
the  cerebral  sinuses.  Among  these  conditions  the  following  may  be 
prominently  mentioned : — 

1.  Compression  of  the  Jugulars. — This  may  be  induced  by  wearing 
of  tight  clothing  around  the  neck,  enlargement  of  the  thj-roid  or  the 
lymphatic  glands,  new  growths  in  the  neck,  or  by  strangulation,  etc. 

2.  A  Dependent  Foxition  of  the  Head. — Aci'obats  are  not  infrequently 
attacked  with  cerebral  congestion.  Any  labor  performed  with  the  head 
down,  or  with  the  body  in  a  stooping  posture,  may  induce  it.  Attacks 
have  been  brought  about  by  straining  at  stool  or  the  buttoning  of  the  shoes. 

3.  Violent  E.rpiratory  Ejf'orts. — Playing  upon  wind  instruments, 
severe  paroxysms  of  coughing,  etc.,  tend  to  prevent  the  entrance  of  blood 
into  the  chest,  and  thus  to  force  too  much  blood  into  the  general  circula- 
tion.    Such  acts  may  prove  an  exciting  cause  of  this  condition. 

Ki 


242 


LECTUKES   ON   NERVOUS   DISEASES. 


4.  Valvular  Disease  of  the  Heart. — When  valvular  defect  exists  at 
the  mitral  or  aortic  orifices,  sutiicient  hypertroph}-  of  the  auricle  or 
ventricle  may  be  tleveloped  to  com[>ensate  for  the  deficiency.  In  this 
case  the  organ  exhibits  no  marked  impairment  of  its  function;  but, 
when  the  compensation  is  disproportionate  to  the  valvular  lesion,  the 
return  of  blood  from  the  head  is  seriously  interfered  with.  Under  such 
circumstances  anything  that  tends  to  over-excite  or  weaken  the  heart's 
action  produces  marked  cerebral  disturbances. 

5.  S^'mptoms  of  cerebral  congestion  are  occasionally  developed  as 


Fig.  78. — Diagram  of  a  Tkansversb  Vertical  Section  of  the  Left  Cerebral  Hemi- 
sphere, SHOWING  THE  ARTERIAL  DISTRIBUTION.  (Modified  slightly  from  We-stbrook.) 
1,  arteries  ramifying  in  the  pia,  and  sending  off  cortical  and  medullary  branches  ;  2,  gray 
matter  of  corte.x  ;  3,  corpus  callosum;  4,  cavity  of  the  ventricle;  5,  caudate  nucleus; 
6,  6',  6",  members  of  lenticular  nucleus  (Glieder)  ;  7,  internal  capsule  ;  8,  septum  ;  9,  optic 
chiasm  ;  10,  arteries  from  circle  of  Willis,  sending  branches  to  basal  ganglia  ;  11,  convolu- 
tions of  Island  of  Reil;   12,  claustrum. 

the  result  of  plethora,  caused  by  excess  in  eating  or  drinking.  It  is 
questionable  to  in^^  mind  if  this  form  is  not  always  associated  with  some 
organic  changes  in  the  arteries, — probably  of  the  atheromatous  type. 

6.  Persistent  Anxiety  or  Emotional  Excitement. — This  is  perhaps  the 
most  common  and  potent  of  all  the  etiological  fiictors  of  cerebral  conges- 
tion. The  prolonged  activity  of  the  brain  protracts  the  determination 
of  blood  to  the  head  (which  is  requisite  to  maintain  that  activity)  beyond 
its  proper  limits.  The  continued  over-distension  of  the  cerebral  vessels 
causes  the  coats  to  lose  their  contractility,  and  thus  active  hypera'mia 
(which   at   first  existed)    Ijccomes   j)assive.     Examples    of    the    marked 


I 


HYPEREMIA    OF   THE   BKAIX    AND    ITS    COVERINGS.  243 

effect  of  emotions  upon  the  eireulation  (if  the  head  are  well  exhibited  in 
the  turgid  face  of  anger,  tlie  blush  of  shame,  and  the  pallor  of  fear. 

7.  Eye-strain  (from  an  uncorrected  refractive  error  or  imperfect 
adjustment  of  the  ocular  muscles)  often  tends  to  excite  and  to  maintain 
passive  cerebral  hy))er}enii:i.  This,  in  my  exj)erience,  is  a  very  common 
cause. 

Symptoms. — The  manifestations  of  the  active  and  passive  varieties 
differ  markedly.  Some  authors  describe  the  symptomatology  of  cerebral 
congestion  as  capable  of  being  divided  into  two  stages, — those  of  active 
hypersemi.M  constituting  the  first,  and  those  of  passive  hypersemia  the 
second.  It  seems  to  me  illogical,  although  perhaps  it  is  clinically  true  in 
a  certain  proportion  of  cases. 

The  actiA'e  form  is  an  independent  condition.  It  may  be  transient ; 
and  is  not  invariably  followed  by  the  passive  variety.  It  is,  moreover, 
cliiefly  if  not  exclusively  encountered  in  those  subjects  that  have  suffered 
from  prolonged  anxiety,  emotional  excitement,  or  mental  strain  that  we 
meet  the  two  as  consecutive  stages. 

Galton  first  called  attention  to  the  utility  of  an  examination  of  the 
drum  of  the  ear  as  a  means  of  determining  the  existence  of  cerebral  con- 
gestion, and  Hammond  and  Roosa  have  used  it  as  a  guide  to  the  con- 
dition of  the  intracranial  circulation  in.  their  experiments  with  the 
internal  administration  of  quinine.  I  have  had  reason  in  several 
instances  to  acknowledge  the  utility  of  this  step.  It  is  necessary  in 
many  cases  to  clear  the  ear  of  wax  before  the  drum  can  be  utilized  for 
this  purpose.  The  tympanum  will  be  congested  over  the  handle  of  the 
malleus  and  be  pink  in  color  when  cerebral  hj-penemia  exists. 

Symptoms  of  the  Active  Variety. — The  cause  of  the  hyperaemia 
will  modify  the  sym^jtoms  in  each  individual  case.  There  is  a  wide- 
spread error  (often  injurious  to  the  patient)  that  all  cerebral  disturbances 
which  cannot  be  traced  to  some  definite  cause  must  be  dependent  upon 
hyperiiemia  or  anaemia  of  the  brain  or  its  coverings.  That  this  is  an 
error  is  proven  conclusively  b}'  the  fact  that  the  quality  of  the  blood  as 
well  as  its  quantity  may  exert  an  influence  upon  the  cerebral  function? 
(as  clinically  observed  in  fevers,  poisoning  by  alcohol,  drugs,  etc.),  and 
that  a  general  overheating  of  the  body  may  produce  the  symptoms  of 
sunstroke  without  actual  exposure  to  the  sun's  rays.  The  cerebral 
hyperemia  which  accompanies  alcoholism,  for  example,  plays  probably 
but  an  insignificant  part  in  the  development  of  the  symptoms  of  that 
condition,  provided  the  use  of  alcohol  has  been  long  continued. 

The  symptoms  of  cerebral  hyperaemia  may  be  classified  under  two 
heads,  viz.,  those  dependent  upon  cerebral  irritation  and  those  indicative 
of  cerebral  depression . 

Under  the  former,  the   following  may    be   prominently  mentioned: 


244  LECTURES    ON   NERVOUS    DISEASES. 

1,  headache,  which  may  he  more  or  less  severe  aud  accompanied  by 
throbhin<r  ;  ^.  nn  increased  sensitiveness  to  light  or  sound;  3,  abnormal 
jihenomena  connected  with  the  special  senses,  such  as  sparks  before  the 
eves,  buzzing  in  the  ears,  formication  in  the  limbs,  and  ill-defined  pains  ; 
4,  motory  S3-mptoms,  such  as  restlessness,  vertigo,  muscular  startings, 
gnashing  of  the  teeth,  vomiting,  convulsions,  etc. ;  5,  disturbance  of  the 
psychical  functions,  such  as  hallucinations,  illusions,  delusions,  melan- 
cholia, etc.;  C),  persistent  insomnia,  which  is  perhaps  more  marked  than 
any  sj'mptom  in  most  cases;  and  7,  a  loss  of  control  over  the  emotions. 
These  patients  are  apt  to  talic  a  grent  deal,  and  to  exhibit  other  mani- 
festations of  mental  exaltation. 

The  effects  of  cerebral  depression  may  be  indicated  by  any  of  the 
following  symptoms :  1,  insensitiveness  to  external  irritation,  such  as  a 
bright  light,  loud  noises,  etc. ;  2,  an  altered  condition  of  the  pupils  ;  3, 
sluggishness  of  the  intellectual  faculties ;  4,  slowness  of  muscular 
movements,  which  ma}'  go  on  to  paresis  or  paralysis  ;  5,  marked  somno- 
lence, possibly  deepening  into  coma;  and  6.  slowing  and  deepening  of 
the  breatliing,  which  maj'  become  stertorous. 

In  all  cases,  the  symptoms  are  increased  by  the  recumbent  posture, 
by  deep  inspirations,  and  by  stimulants. 

All  possible  combinations  of  the  symptoms  of  either  of  the  two 
varieties  described  va&j  be  encountered  in  an}-  individual  case.  Some  of 
the  more  important  deserve  special  mention. 

Insomnia  is  a  very  common  s^-mptom  of  cerebral  irritation.  If  sleep 
is  not  actually  prevented,  it  is  liable  to  be  markedly  disturbed  by  bad 
dreams  and  fails  to  refresh  the  patient. 

Headache  and  throbbing  in  the  head  is  a  very  constant  symptom. 
The  pain  may  be  either  of  a  dull,  aching  character,  or  extremely  severe. 
It  is  gretitly  aggravated  by  stooping,  deep  inspirations,  or  muscular  and 
mental  exertion.  Stimulants  usually  increase  it.  In  many  eases  com- 
pression of  the  carotids  relieves  it. 

Prolonged  mental  eftbrts  bring  about  a  confusion  of  intellect  earl}-, 
in  many  cases.  This  is  particularly  noticeable  when  mental  exercises 
requiring  concentration,  such  as  adding  up  columns  of  figures,  solving 
of  mathematical  problems,  reading  of  philosophical  works,  etc.,  are 
attempted.  To  this  symptom  ma\-  sometimes  be  superadded  delusions, 
illusions,  hallucinations,  melancholia,  morbid  fears,  and  a  loss  of  emo- 
tional control. 

Vertigo  is  a  very  constant  and  important  symptom.  It  may  be  so 
severe  as  to  prevent  the  patient  from  attending  to  his  business.  It  may, 
furthermore,  be  associated  with  unnatural  sensations  in  the  head,  such  as 
a  sense  of  constriction,  a  snapping  noise,  an  encircling  band,  a  burning 
sensation,  etc. 


HYPEE^MIA   OF  THE   BRAIN    AND   ITS    COVERINGS.  245 

The  motory  symptoms  are  sometimes  coiitiued  to  one  side,  but  this  is 
not  iihva^'S  the  case.  Paresis  or  actual  paralysis  sometimes  develops 
suddenly  in  an  arm  or  leg,  or  both.  All  of  the  limbs  are  simultaneously 
art'ected  in  rare  cases.  Convulsive  twitchings  may  develop  in  the  muscles 
of  the  face  and  limbs.  The  heart  is  liable  to  exhibit  a  marked  accelera- 
tion in  the  frequency  of  its  beats  after  slight  exertion,  and  to  develop 
paroxysms. of  palpitation.  This  is  independent  of  au}'^  organic  lesion, 
and  is  to  be  attributed  to  cerebral  disturbance.  Respiration  may  become 
similarly  disturbed  when  the  heart  becomes  unduly  excited.  Aphasia 
is  sometimes  developed,  either  independently  of  or  in  conjunction  with 
l)aral3'sis  of  the  limbs.  It  is  usually  transient.  Convulsions  may  occur 
in  the  advanced  stages  of  cerebral  hyperaemia.  They  differ  from  those 
of  epilepsy  in  the  absence  of  an  aura  and  the  epileptic  cry. 

The  psychical  symptoms  are  sometimes  })rominent.  A  gradual 
stupor  may  develop  in  some  cases,  accompanied  with  pain  in  the  head  and 
dilated  pupils.  Again,  mania  may  occur,  with  active  delirium  and  a 
tendency  to  acts  of  violence.  These  states,  however,  are  preceded  in 
every  case  by  some  of  the  premonitory  symptoms  that  have  been  pre- 
viously enumerated. 

Symptoms  of  the  Passive  Variety. — The  symptoms  of  irritation 
are  less  marked  in  this  form  thtni  those  of  cerebral  depression.  Although 
all  of  those  enumerated  in  previous  pages  may  occur  in  the  passive 
variety  as  well  as  in  the  active,  it  is  more  common  to  meet  with  somno- 
lence early  instead  of  insomnia,  and  to  find  all  the  irritative  symptoms 
subordinate. 

Whenever  the  congestion  is  attended  with  an  exudation  of  serum 
we  are  liable  to  encounter  paralysis,  convulsions,  deep  coma,  maniacal 
attacks,  or  aphasia.  This  form  of  hyperaemia  is  more  liable  to  serous 
effusion  than  the  active,  and  is  therefore  a  more  serious  disease. 

Passive  cerebral  hyperajmia  is  particularly  prone  to  pass  into  that 
stage  where  alarming  symptoms  appear.  It  is  not  uncommonly  fatal. 
In  some  cases  it  induces  a  condition  of  body  that  is  diagnosed  witli  difti- 
culty  from  apoplexy. 

If  convuhious  develop,  they  are  generally  of  longer  duration  than 
if  due  to  active  hyperaemia,  and  are  followed  by  a  more  profound  stupor. 
The  tongue  may  be  severely  bitten.  The  fit  may  be  followed  by  paral3'sis. 
The  mind  appears  to  suffer  rapid  deterioration  after  the  convulsive 
attacks  develop. 

Whenever  mania  ensues  the  patient  seldom  exhibits  as  active 
delirium  as  in  the  previous  form  of  cerebral  hyperaemia,  nor  are  acts  of 
violence  as  common. 

The  ophthalmoscope  will  usually  show  a  marked  turgescence  of  the 
retinal  veins  in  tiiis  form  of  cerebral  hypertemia. 


246  LECTURES     ON     NERVOUS     DISEASES. 

Differential  Diagnosis. — The  history  and  examination  of  the  patient 
is  an  inipuittuil  I'uctor,  because  it  aids  in  deciding  as  to  the  existence  of 
hysteria,  chlorosis,  alcoholism,  venereal  excesses,  seminal  weakness,  dis- 
eases of  the  heart,  lungs,  or  abdominal  viscera,  and  many  other  conditions 
that  often  tend  toward  the  development  of  cerebral  hyperainiia. 

From  cerebral  hemorrhage  this  condition  ditters  in  that  conscious- 
ness is  seldom  completely  abolished  ;  that  the  paral^'sis  is  not  unilateral 
as  a  rule  ;  that  sensation  and  motion  are  seldom  simultaneously  impaired 
or  lost ;  and  that  the  symptoms  are  of  shorter  duration. 

From  embolism,  it  ditters  in  that  premonitory  symptoms  have  existed  ; 
that  the  paral3-sis  is  of  shorter  duration ;  that  the  pulse  is  slowed  rather 
than  accelerated  at  the  time  of  the  attack;  that  the  temperature  of  the 
head  is  elevated  ;  and  that  cardiac  disease  is  usually  present  in  embolism. 

From  epilepsy  it  is  to  be  told  by  the  absence  of  an  aura  and  of  the 
epileptic  cry  ;  the  existence  of  premonitory  symptoms ;  the  staggering 
before  an  attack  ;  the  absence  of  facial  i)allor  before  the  fit ;  and  the  in- 
frequent biting  of  the  tongue. 

From  uraemia  the  diagnosis  is  made  by  the  waxy  pallor  of  the  face 
in  renal  disease ;  also  the  absence  of  albumen  and  casts  in  the  urine  ; 
the  infrequency  of  nausea  or  vomiting;  the  absence  of  oedema  of  the 
eyelids  and  possibly  of  the  extremities,  and  the  infrequent  convulsions. 

From  cerebral  softening  it  is  distinguished  by  the  aggravated  char- 
acter of  mental  impairment  of  that  malady,  together  with  the  progressive 
interference  with  articulate  speech.  The  gradnal  onset  of  paralysis  pre- 
ceded by  feebleness  of  gait  in  some  cases,  and  the  development  of  a 
persistent  hemiplegia  with  a  sudden  loss  of  consciousness  would  point 
to  the  more  grievous  malady. 

From  stomachic  vertigo,  the  presence  of  marked  gastric  derange- 
ment in  connection  with  such  attacks  of  dizziness  (which  is  often 
wanting  in  congestive  vertigo)  aids  in  the  diagnosis. 

Treatment. — The  multiplicit}'  of  causes  of  this  affection  would  nat- 
urally suggest  that  the  treatment  must  be  modified  by  the  history  of  the 
patient.  It  is  important,  furthermore,  that  the  diagnosis  be  carefully 
matle  before  any  line  of  treatment  is  commenced.  This  is  not  always  an 
easy  matter.  It  is  especially  diflicult  in  some  cases  to  decide  between 
cerebral  hyperjemia  and  anaemia. 

The  ACTIVE  VARIETY  recpiires  measures  that  Avill  tend  to  lessen  the 
action  of  the  heart  and  diminish  the  quantity  of  blood  in  the  cerebral 
A'essels.  Leeches  to  the  temporal  region  or  within  the  nostril,  or  at  the 
neck  close  to  the  skull,  will  often  prove  of  immediate  benefit.  The  actual 
cautery  applied  to  the  neck  near  to  the  base  of  the  brain,  and  the  gal- 
vanic current  so  used  as  to  stimulate  the  main  sympathetic  nerves  in 
the  neck,  both  tend  to  cause  a  diminution  in  the  calibre  of  the  cerebral 


HYPEREMIA   OF   THE   BRAIN   AND    ITS   COVERINGS.  247 

vessels,  aud  are  therefore  useful.  My  experience  with  the  cautery  lias 
led  me  to  believe  that  it  is  more  prompt  in  its  effects  than  an}'  other 
single  remedial  measure.  It  is  comparatively  painless  when  properly 
used.  Heav}'  static  sparks  from  Leyden-jars  applied  to  the  neck  are 
sometimes  of  great  benefit. 

Sleeping  with  the  head  raised  (especially  with  the  arms  placed  above 
the  head)  will  help  to  decrease  the  amount  of  blood  in  the  brain.  Stooping 
should  be  avoided.  Severe  muscular  exercise  increases  the  heart's 
action;  hence  it  should  be  prohibited  in  this  class  of  cases.  The  clothes 
should  not  press  tightly  upon  the  neck,  as  it  tends  to  impede  the  venous 
return  from  the  head. 

Warm  baths  to  the  feet,  mustard  plasters  over  the  stomach,  and 
cold  effusions  to  the  head  and  neck  are  valuable  adjuncts  to  treatment 
in  some  instances,  since  the}'  all  tend  to  decrease  the  amount  of  blood  in 
the  cranial  vessels. 

Among  the  internal  remedies  employed  by  me  in  this  affection  (after 
all  recognizable  causes  have  been  removed  without  a  cessation  of  tlie 
symptoms)  are  the  bromides  of  sodium  and  potassium,  ergot,  oxide  of 
zinc,  phosphorus,  strychnia,  and  arsenic.  The  internal  administration  of 
hot  water,  according  to  the  rules  given  in  my  paper  upon  this  agent.* 
is  often  attended  with  great  benefit. 

The  bromides  and  the  ergot  exert  an  immediate  effect  upon  the 
amount  of  blood  within  the  cerebral  vessels,  causing  a  very  marked 
decrease,  as  was  first  proven  experimentally  by  Hammond.  I  have  found 
ergot  a  very  valuable  adjunct  to  the  bromides.  They  are  best  given  by 
dissolving  the  bromide  in  a  fluid  extract  of  ergot.  The  following  formula 
is  an  excellent  one : — 

I^.     Potasii  bromidi .    .       •    •        §  j. 

Ergota  ext.  fluidi i  iv. 

M.  Ft.  sol. 

Sig. — Dose,  a  teaspoouful  after  each  meal. 
In  place  of  ergot,  ergotin  may  be  substituted  (in  doses  of  five  grains) 
in  pill  three  times  a  day,  where  the  taste  of  the  fluid  extract  is  disa- 
greeable to  the  patient. 

I  am  inclined  to  lay  stress  upon  the  beneficial  effect  of  the  oxide  of 
zinc,  when  given  in  connection  with  ergot,  tlie  bromides,  and  the  hot- 
water  treatment,  which  will  be  described  later.  It  should  be  given  three 
times  a  day  (in  doses  of  two  grains)  in  pill  after  eating,  as  it  is  less  liable 
then  to  cause  nausea.  By  the  use  of  these  three  drugs  and  hot  water  as 
a  beverage  the  symptoms  will  usually  disappear  inside  of  two  weeks. 
It  is  then  advisable  to  begin  a  course  of  tonic  treatment. 

The  tonics  that   are    commonly   employed   are  quinine,  strychnia, 
arsenious  acid   and   other   arsenic  preparations,  hydrobromic  acid,  and 
*  .V.  Y.  Med.  Jour.,  Oc-tober  17,  1884. 


248  LECTUIJES    ON    NEKVOUS   DISEASES. 

« 

phosphorus,     I   have  used  Warburg's  tincture  with  excellent  effects  in 

doses  of  from  one  to  two  drachms  after  each  meal. 

In  regard  to  ([uiniue.  I  have  tried  the  hydrobromii-  acid  with  good 
results  in  combination.  It  undoulitedly  relieves  the  unpleasant  head- 
S3'mptoms  of  the  (juinine. 

Phosphorus  should  be  given,  when  indicated,  in  doses  varying  from 
one-tiftieth  to  one-hundredth  of  a  grain.  It  may  be  administered  either 
in  an  emulsion,  a  capsule,  a  pill  (by  the  aid  of  resin),  or  in  the  form  of 
the  pliosphide  of  zinc. 

Arsenious  acid  is  highly  recommended,  in  doses  of  one-fiftieth  of  a 
grain,  as  a  substitute  for  other  arsenical  preparations.  My  experience 
with  it  is  too  limited  as  yet  to  enable  me  to  form  any  positive  conclusion 
regarding  it. 

Dyspeptic  symptoms  should  l)e  treated  by  keeping  the  bowels  open 
and  the  continued  use  of  hot  loater  as  a  beverarje,  a  gobletful  being 
drank  one  hour  and  a-half  before  each  meal,  with  the  temperature  as 
high  as  it  can  l)e  borne  (110-^-150°).  Twenty  minutes  may  be  consumed 
in  sipping  a  goblet-full  when  necessary. 

Irrespective  of  dyspeptic  symptoms,  I  have  been  in  the  habit,  how- 
ever, of  recommending  this  treatment  to  nearly  all  of  my  nervous 
patients.  Its  effects  have  proven  quite  remarkable  in  my  hands.  It 
increases  downward  peristalsis,  which  warm  Avater  does  not  (as  the  latter 
is  an  emetic) ;  it  stimulates  the  secretion  of  urine,  and  alters  its  character 
with  great  rapidity ;  it  produces  a  gentle  perspiration  after  drinking  it, 
and  a  sense  of  warmth  in  the  skin;  it  relieves  dyspeptic  symptoms  better 
than  charcoal  and  bismuth,  if  continued  long  enough;  finally,  it  seems 
to  act  upon  the  S3'mpathetic  system  (probably  by^  affecting  the  solar 
plexus),  as  is  shown  by  the  relief  of  most  forms  of  local  hypersemia.  It 
must  be  taken,  however,  with  absolute  regularity,  one  hour  and  a-half 
before  every  meal,  so  as  to  get  the  effect  of  the  heat  and  to  wash  out  the 
stomach  before  the  ingestion  of  food.  A  little  lemon  or  flavoring  of  any 
kind  may  be  added,  if  the  taste  is  disagreeable;  although  patients  soon 
learn  to  crave  it  without  such  additions.  Carlsbad  salts  may  be  added 
to  the  morning  dose,  if  constipation  exists.  In  some  cases  it  becomes 
necessary  to  restrict  certain  articles  of  food  during  the  hot-water  treat- 
ment. I  have  published  the  methods  emi)loyed  by  me  in  full  in  a 
brochure*  upon  the  subject,  to  which  the  reader  is  referred. 

In  the  PASSIVE  variety  of  cerebral  hypersemia  the  indications  for 
treatment  are  to  increase  the  heart's  power  and  assist  the  venous  return 
from  the  cerebral  sinuses. 

Stimulants  are  strongly  indicated,  therefore,  in  many  cases,  in  con- 
junction with  the  other  methods  of  treatment  previously  suggested  to 
*iV^.  T.  Jled.  Jour.,  October  16,  18Si. 


ANEMIA   OF   THE   BEAIN    AND    ITS   MEMBRANES.  249 

relieve  the  congestion  of  the  vessels.  Alcohol,  snlphui-ic  ether  (hy 
inluilation  or  the  stoniuch),  c;irl)onate  of  amnionic,  and  (li<i;italis  may  be 
employed  often  with  marked  benelit. 

The  habits  of  the  patient  should  be  controlled,  provided  that  excesses 
of  any  kind  exist,  and  are  thought  to  be  injurious.  Tobacco,  tea,  coffee, 
opium,  etc.,  may  be  factors  both  in  the  causation  and  persistence  of  the 
cerebral  congestion. 

Success  in  treatment  of  passive  cerebral  hj  perremia  will  depend 
chietly  upon  the  removal  of  the  exciting  cause  of  the  condition.  It 
should  be  coupled  with  such  advice  as  to  exercise,  mental  work,  bathing, 
eating,  drinking,  etc.,  as  will  tend  to  prevent  its  return  by  promoting  a 
general  improvement  in  health. 

Static  insulation  and  a  fusillade  of  sparks  to  the  spine  seem  to  give 
these  patients  relief.  I  often  employ  the  umbrella-head-electrode  in  these 
cases  with  satisftictory  results.  The  static  machine  used  must  be  suffi- 
ciently powerful  (when  this  is  employed)  to  generate  large  quantities  of 
electric  it}'. 

AN.EMIA   OF   THE   BRAIN   AND   ITS   MEMBRANES. 

Kussmaul,  Bonders,  and  Tenner  have  observed  the  phenomena  of 
marked  cerebral  anaemia  through  a  glass  plate  inserted  in  the  skull  of 
animals;  and  Nothnagel,  Loven,  Mayer,  and  Pribam,  and  many  others 
have  proven  the  possibility  of  artificially  producing  it.  These  lacts  are 
mentioned  because,  for  a  time,  the  existence  of  this  condition  as  a  dis- 
tinct disease  was  denied.  Cerebral  anaemia  may  be  localized  or  general. 
The  latter  is  the  most  common  variety.  The  symptoms  of  this  condition" 
are  modified  (1)  by  the  variety  and  (2)  by  the  method  of  its  development 
(whether  sudden  or  gradual),  irrespective  of  its  intensity. 

Morbid  Anatomy. — The  meningeal  vessels  are  usually  nearly  empty  ; 
although,  in  some  cases,  meningeal  hypercemia  may  coexist  with  cerebral 
angeraia.  The  pia  usually  contains  some  serum  in  its  meshes.  The 
medullary  substance  of  the  brain  is  of  a  dull,  white  color,  and  presents  on 
section  few,  if  any,  vascular  spots.  The  masses  of  gray  substance  are 
poorly  defined  in  their  outline,  in  sagittal  or  transverse  sections  of  the 
brain.  They  are  dryer  and  firmer  than  normal,  in  case  the  anaemia  has 
persisted  for  some  time,  or  when  it  exists  in  connection  with  general 
anaemia  or  chlorosis. 

In  connection  with  partial  cerebral  anaemia  it  is  common  to  find  the 
adjacent  ai'eas  markedly  li^'perfBmic.  This  hyperemia  may  occasionally 
exist  also  in  parts  somewhat  removed  from  the  anaemic  territory.  It  is 
due  to  excessive  arterial  tension  in  the  vessels  whose  supply  is  not  inter- 
fered with. 

If  the  condition  of  cerebral  anaemia  has  been  developetl  as  a  result 


2r)0  LECTURES   ON   NEEVOUS  DISEASES. 

of  localized  pressure  (as  in  tlie  case  of  cerebral  tumors,  large  extravasa- 
tions of  blood,  enceplialitis,  etc.)  the  convolutions  of  the  brain  may  be 
tiattened  or  otherwise  distorted. 

According  to  the  researches  of  Golgi,  iii  all  forms  of  cerebral  anaemia 
the  perivaseulnr  spaces  are  enlarged,  even  if  oedema  l)e  present. 

Etiology. — 'I'he  causes  of  this  condition,  when  widely  diffused  or 
partial,  can  be  classified  under  several  heads,  as  follow: — 

1.  TAose  Causi7ig  a  Diminution  of  the  Space  Within  the  Skull. — Untler 
this  head  uiay  be  mentioned  all  forms  of  exudation,  new  growths,  and 
blood  extravasations.  Tumors  and  blood  extravasations  tend  to  produce 
definitely  localized  pressure  upon  the  adjacent  areas  of  the  brain.  Exu- 
dations (when  very  extensive)  may  result  in  a  more  diffused  pressure. 
The  brain  may  be  more  or  less  distorted  in  its  outlines  from  all  of  these 
causes. 

2.  Compression  or  Obstruction  of  the  Arteries  that  Supply  the  Brain 
with  Blood. — Under  this  head  come  embolism,  thrombosis,  ligation, aneu- 
rism, pressure  of  new  growths  upon  the  vessels,  etc.  Fortunately  for  life, 
the  "circle  of  Willis"  allows  of  a  collateral  circulation  in  case  of  ligation 
or  other  causes  of  obstruction  to  the  vessels  of  one  side  of  the  neck. 
Ligation  of  both  carotids  or  a  severe  loss  of  blood  from  any  large  artery  or 
vein  is  followed  invariably  l)y  the  symptoms  of  general  cerebral  anaemia. 

The  circle  of  Willis  unquestionably  prevents  in  the  majority  of  sub- 
jects general  cortical  anaemia  of  one  hemisphere,  in  case  of  ligation  of 
the  carotid  or  other  obstruction  to  its  calibre.  But  it  is  questionable  if 
the  basal  ganglia  are  not  more  liable  to  ischa?mia  from  such  causes  than 
the  cortex.  The  anastomoses  are  less  frequent  in  these  gray  nuclei  than 
upon  the  surface  of  the  cerebrum,  and  sometimes  the  branches  of  the 
circle  of  Willis  are  impervious  or  imperfectly  developed.  Elirmann 
found  about  20  per  cent,  of  cases  (selected  at  random)  to  exhibit  defects 
in  the  vessels  mentioned. 

3.  Overloading  of  Other  Organs  xcith  Blood. — Severe  catharsis,  ex- 
tensive dry  cupping,  an  enfeebled  heart's  action,  and  simple  gravitv  may 
induce  cerebral  anaemia.  As  an  illustration  of  the  last  cause,  conva- 
lescents from  protracted  fevers  or  debilitating  diseases  often  l:iint  Avhen 
the}'  attempt  to  sit  up. 

4.  Direct  Abstraction  of  Blood  from  the  Brain. — In  case  of  a  severe 
hemorrhage  from  some  vessel  of  the  trunk  or  extremities,  the  brain  is 
rendered  anajmic  earh*. 

I  have  witnessed  in  a  few  instances  the  most  profound  symptoms  of 
cerebral  anaemia  in  connection  with  severe  epistaxis,  metrorrhagia,  intes- 
tinal hemorrhage,  and  after  an  operation  for  lu>?morrhoids.  The  applica- 
tion of  Junod's  boot  may  deprive  the  brain  of  its  Itlood,  and  thus  induce 
cerebral  anasmia  mechanicallv. 


ANEMIA   OF   THE   BEAIN   AND    ITS   MEMBRANES,  251 

5.  Poverlij  of  the  Blood. — In  this  case  the  amount  of  the  bhjod 
within  the  cerebral  vessels  may  be  normal,  and  still  the  brain  be  anaemic 
because  the  quality  of  the  blood  fails  to  properly  nourish  it.  Examples 
of  this  are  encountered  in  bottle-fed  babies,  and  in  connection  with  the 
fevers,  leuka-mia,  chlorosis,  tuberculosis,  malarial  cachexia,  prolonged 
lactation,  chronic  suppuration,  starvation,  etc. 

6.  Vaso-motor  Disturbance. — Strong  and  sudden  emotions,  shock, 
cerebral  concussion,  electric  stimulation  of  the  sympathetic  cords,  etc., 
are  not  infrequently  followed  by  symptoms  of  cerebral  anannia,  such  as 
pallor,  vertigo,  insensibility  of  some  of  the  special  senses,  and  a  weak- 
ness of  the  action  of  the  heart. 

Symptoms. — It  is  important  but  not  always  an  easy  matter  to  diag- 
nose cerebral  anamia  from  the  condition  of  cerebral  hyperemia.  Not 
only  is  this  discrimination  important  from  a  scientific  standpoint,  but  the 
life  of  the  patient  may  be  imperilled  by  an  error  in  diagnosis  (especially 
in  infancy)  because  the  treatment  of  the  two  conditions  is  directly  opposed. 

Sudden  cerebral  anaemia  produces  symptoms  that  ditfer  from  those 
of  the  form  which  is  gradually  developed.  In  the  former  a  "  fainting 
tit"'  is  produced.  An  attack  of  this  character  usuall}-  begins  with  dizzi- 
ness, a  sense  of  impaired  vision,  and  a  loss  of  the  normal  appreciation  of 
sensory  impressions.  The  patient  becomes  incapable  of  voluntar}'  move- 
ment, gradually  sinks  to  the  ground  and  loses  consciousness.  The  pupils 
dilate,  the  face  becomes  pale,  the  respirations  are  slow  and  shallow,  and 
slight  spasms  of  the  muscles  occur.  Gradually  the  patient  regains  con- 
sciousness, and  the  other  symptoms  slowlj^  disappear.  In  rare  cases, 
however,  death  ensues  without  a  return  of  consciousness. 

In  infants,  cerebral  anaemia  is  liable  to  be  confounded  with  acute 
hydr(X'ei)halus.  The  child  is  restless  and  capricious;  tosses  about, 
gnashes  the  teeth,  and  cries  out  in  sleep.  The  face  is  often  flushed  in  the 
early  stages,  but  tends  to  become  pale.  The  temperature  and  pulse  may 
l)e  increased.  Sleep  is  interrupted  by  attacks  of  crying  in  man}'  in- 
stances. Twitchings  of  the  limbs  and  even  convulsions  are  liable  to  be 
developed.  The  fontanelle  is  depressed.  Later  in  the  attack  the  patient 
becomes  insensible  to  light,  noises,  or  objects  held  before  the  eyes  ;  the 
eyelids  remain  half  closed;  the  pupils,  which  were  contracted  in  the  early 
stage,  now  become  dilated  ;  the  pulse  flutters  and  is  irregular;  the  respira- 
tion grows  shallow,  noisy,  and  infrequent ;  the  sphincters  are  not  con- 
trolled; and  death  comes  at  last,  preceded  by  complete  coma.  Strabis- 
mus and  rigidity  of  the  muscles  at  the  nape  of  the  neck  may  occasionally 
be  observed  during  the  attack. 

In  older  patients  the  symptoms  of  gradual  development  of  cerebral 
anaemia  diflTer  (1)  with  the  variet}'  present — general  or  partial — and  (2) 
with  the  severit}'  (so  to  speak)  of  the  aujsmia. 


252  LECTI'KES   ON   NERVOrS   DISEASES. 

The  more  [iroinineiit  signs  of  the  general  variety  are  headache,  ver- 
tigo, nausea,  dimness  of  vision,  and  fainting  or  convulsive  attacks. 
Muscular  weakness,  drowsiness,  flashes  of  light  Ijefore  tlie  ejes,  roarings 
in  the  ears,  a  dread  of  mental  or  physical  effort,  tremor  after  exercise, 
and  mental  confusion  may  precede  the  attacks  of  syncope  or  convulsions. 

T\\e  }>artial  variety  is  commonly  due  to  tumors,  oedema,  eml»olism. 
or  thrombosis.  The  symptoms  will  vary  with  the  area  of  the  brain  that 
is  rendered  anaemic.  Motor  paralj'sis  (monoplegia  or  hemiplegia)  may 
follow  if  the  cortex  of  the  "  motor  area  "  of  the  cerebrum  is  deprived  of  its 
nutrition.  Again,  aphasia  may  be  the  result  of  ansemia  of  the  base  of  the 
third  frontal  convolution,  the  island  of  Reil,  or  the  adjacent  medullary- 
substance.  Vision  may  be  impaired  if  the  cortex  of  the  occipital  convo- 
lutions are  aft'ected  or  the  other  mass  of  gray  matter  with  which  the 
optic  fibres  are  known  to  be  associated.  Finally  hearing  or  smell  may  be 
impaired  hy  anaemia  of  the  temporal  lobes,  and  tactile  sensibility  may  be 
impaired  if  the  parietal  cortex  be  deprived  of  its  normal  blood-supply. 
Fig.  5  will  enable  the  reader  to  appreciate  the  grounds  for  these  state- 
ments. Some  of  the  more  important  points  in  cerebral  localization  will 
be  discussed  later,  chiefly  in  connection  with  cerebral  hemorrhage. 

Delirium  and  hallucinations  are  not  infrequently  observed  in  con- 
nection with  cerebral  anjemia.  Occasionallj^  the  delirium  may  assume  a 
maniacal  type.  In  other  instances  melancholia  may  be  a  prominent 
sj-mptom. 

Nothnagel  states  that  smell  and  taste  are  never  affected  in  cases  of 
cerebral  ana?mia.  My  own  experience  leads  me  to  doubt  the  accuracy 
of  this  statement.  It  is  more  common  to  observe  symptoms  referable 
to  the  optic  and  acoustic  apparatus,  but  hyperosmia  and  hypergeusia 
have  been  present  in  some  cases  that  have  fallen  under  my  observation. 

DifFerential  Diagnosis. — The  diseases  most  liable  to  be  confounded 
with  general  cerebral  anaemia  are  cerebral  hyperiiemia  and  hydrocephalus. 

From  cerebral  hypersemia  the  diagnosis  is  often  difficult.  The  ap- 
parent cause  is  an  important  factor  in  the  discrimination.  Moreover,  the 
pallor  of  the  face,  the  fainting  attacks,  the  dimness  of  vision,  and  drow- 
siness are  characteristic  of  anaemia.  The  ophthalmoscope  maj'  enable 
the  physician  to  detect  anaemia  of  the  retinal  vessels.  The  vertigo  of 
antemia  is  diminished  by  a  recumbent  posture,  and  increased  by  stand- 
ing. Finally,  the  effects  of  stimulants  and  the  inhalation  of  a  few  drops 
of  the  nitrite  of  amyl  will  be  markedh'  beneficial  in  anremia,  while  such 
agents  will  increase  the  symptoms  of  congestion. 

From  IiydrocejjhahiK  the  diagnosis  is  to  be  made  by  the  absence  of  a 
history  of  tuberculosis  in  the  parents,  the  presence  of  some  of  the  ex- 
citing causes  of  anaemia,  and  the  age  of  the  subject.  There  is  probably 
little  ditference  in  the  two  diseases,  as  far  as  the  condition  of  the  cere- 


ANEMIA   OF   THE   BRAIN    AND    ITS   MEMBRANES.  253 

bral  vessels  is  concerned.  The  tubercular  deposit  at  the  base  of  the 
brain  in  hydrocephalus  undoubtedly  produces  most  of  its  ettects  by 
pressure  upon  the  cerebral  vessels. 

Prognosis. — In  adults,  the  prognosis  in  cerebral  anjBmia  is  favorable 
if  we  are  able  to  relieve  the  exciting  cause,  lu  children,  cerebral  anaemia 
"may  prove  fatal  if  following  an  exhausting  diarrhoea,  marasmus,  or 
debility.  Kussmaul  states  that  when  the  pupils  have  become  dilated 
a  return  of  tlie  mobility  is  a  favorable  omeu. 

Treatment. — The  indications  for  treatment  vary  with  the  exciting 
cause.  Stimulants  and  the  inhalation  of  from  four  to  eight  drops  of  the 
nitrite  of  annd  three  times  a  da}'  by  an  adult  will  generally  cause  a  rapid 
improvement  in  the  symptoms  after  the  cause  has  been  removed.  Alco- 
holic liquors  should  be  given  in  small  doses,  and  repeated  frequentl}^  till 
the  heart-power  is  increased  and  the  symptoms  show  improvement. 
They  should  not  be  pushed  beyond  reasonable  limits.  The  ditlusible 
stimulants  are  only  advisable  when  a  rapid  effect  is  sought  for,  or  when 
alcohol  disagrees  with  the  patient.  Opium  tends  to  increase  the  flow  of 
blood  to  the  head ;  hence  it  is  sometimes  very  happy  in  its  ell'ects  when 
administered  in  one-quarter-grain  doses  three  times  a  day  for  a  few  weeks. 

When  aujcmia  of  the  blood  exists,  iron  and  some  of  the  bitter  tonics 
are  of  great  benefit.  If  hemorrhage  has  been  a  factor  in  the  case,  the 
recumbent  posture  should  be  maintained  rigorously  until  the  pr.tient  has 
regained  strength  and  manufactured  blood  to  till  the  depleted  vessels. 
Tying  the  arms  and  legs  after  a  serious  hemorrhage,  in  order  to  force 
the  blood  to  the  head,  may  s<jmetimes  be  demanded.  Raising  the  foot 
of  the  bed,  upon  which  the  patient  is  lying,  upon  two  chairs  will  also 
help  to  determine  blood  to  the  lirain.  In  obstetric  practice,  this 
manoeuvre  is  often  employed  to  arrest  the  brain  symptoms  after  flooding. 

During  convalescence,  restrictions  regarding  excessive  phjsical  or 
mental  exercise  should  be  placed  upon  the  patient.  All  forms  of  excite- 
ment should  be  avoided.  I  have  twice  known  insanity  to  follow  emotional 
excitement,  after  this  condition  of  cereliral  ana*mia  has  existed  to  marked 
degree. 

The  advisability  of  employing  galvanism,  although  sustained  by 
Hammond  and  other  authorities  of  note,  is  to  my  mind  questionable. 
Personally,  I  have  seldom  o]>served  any  decidedly  beneficial  ettects 
from  its  use.  Whenever  it  is  em])loyed,  the  current  should,  as  a  rule,  be 
an  extremely  mild  one,  and  the  duration  of  its  employment  short.  I 
greatly  prefer  static  insulation,  followed  l)y  sparks  to  the  nape  of  the 
neck,  when  such  applications  are  feasible. 

Finally, care  in  regulating  the  diet  and  the  functions  of  the  ;d)dominal 
organs  is  very  essential  to  a  complete  recovery.  I  would  again  urge 
here  the  use  of  the   hot-water  trentnient,  which  I  have  described  on  a 


254  LECTUKES   ON    NERVOUS   DISEASES. 

pr<.'vi(ni!s  |).age  in  (lisciissiiitr  ciMvltial  hypeiwinia.  A113'  form  of  disturb- 
ance of  the  circulator}  uppanitus  seems  to  be  modilied  and  generally 
improved  by  the  action  of  heat  upon  the  solar  plexus.  The  treatment 
of  the  most  important  sj^mptom  of  partial  cerebral  anaemia  (aphasia)  hius 
been  considered  under  the  treatment  of  cerebral  embolism. 

CEREBRAL    HEMORRHAGE. 

Tlic  blood-vessels  of  the  meninges  or  of  the  brain  sometimes  rupture, 
and  thus  allow  of  an  escape  of  blood  into  adjacent  structure. 

If  the  extravasation  be  meningeal,  its  effects  are  exerted  chiefly 
upon  the  gray  matter  of  the  convolutions  (tiie  cerebral  cortex).  If 
within  the  substance  of  the  cerebrum,  tracts  of  filires  are  torn  across  by 
the  escaping  blood,  and  are  thus  separated  from  their  connection  with 
the  cortical  cells, 

Intra-cerebral  hemorrhages  may  exert  pressure-etfects  upon  the 
ventricles,  in  case  the  blood  fails  to  enter  these  cavities,  and  thus  create 
a  more  or  less  complete  obstruction  to  the  ingress  and  egress  of  the 
cerebro-spinal  fluid. 

Because  the  symptoms  of  pressure  upon  the  ditferent  parts  of  the 
brain  are  observed  in  patients  afflicted  with  tumors,  depressed  bone, 
abscess,  and  extensive  exudation,  as  well  as  in  connection  with  hemor- 
rhage, any  remarks  made  in  reference  to  the  localization  of  blood-clots 
applies  as  well  to  many  of  these  conditions. 

Morbid    Anatomy. The    middle   meningeal    artery   is    the    most 

frequent  source  of  surface  hemorrhage — ^the  extravasation  that  occurs 
in  connection  with  jjachy meningitis  being  excluded  from  this  head,  as  it 
is  of  inflammatory  origin.  This  vessel  of  the  brain  is  particularly  liable 
to  be  involved  in  direct  injuries  to  the  cranial  vault.  Its  jirea  of  distri- 
bution to  the  meninges  corresponds  approximately  to  that  portion  of  the 
cerebral  cortex  which  contains  the  motor  centres  (see  Fig.  5).  For  this 
reason  the  lilood  extravasated  from  that  vessel  is  particularly  prone  to 
press  upon  the  motor  convolutions  beneath.  Actual  damage  may  be 
done  to  these  cortical  centres  if  the  blood  escapes  in  sufficient  quantities 
to  impair  the  structural  integrity  of  parts  beneath  the  clot.  Otherwise 
the  cortex  is  rendered  simply  ansiemic  at  the  seat  of  pressure.  It  may 
regain  its  function,  in  such  a  case,  when  the  pressure  is  relieved  by  the 
use  of  trephine  or  the  gradual  absorption  of  the  clot. 

Structural  changes  in  the  motor  convolution  are  almost  invariably 
followed  by  a  descending  sclerosit^  of  those  fibres  that  are  anatomically 
associated  with  the  cortical  cells  destroyed.  This  sclerosis  can  often  be 
traced  into  the  substance  of  the  spinal  cord.  In  this  way  the  motor 
function  of  Tiirck's  columns  and  of  the  crossed  pyramidal  tracts  in  the 
spinal  cord  (Fig.  29)  has  been  established  beyond  dispute. 


CEEEBEAL   HEMOREHAGE. 


255 


The  following  simple  diagram  will  possibly  aid  the  reader  in  master- 
ing the  more  essential  anatomical  facts  that  pertain  to  motor  paralysis 
of  cerebral  origin.  It  is  designed  purely  for  the  purpose  of  teaching, 
and  must  not  be  construed  as  a  representation  of  the  parts  in  their 
proper  relations  to  vdc\\  other: — 


Mor^Sff^l'T^^^^^-ZJ^''. 


\lElfJU  OPBKSe 
<  or  CEK.EMRML 
(  M£M/SPM^RES 


/i£6/OJf  Off 

THE 
SPJHML  COMO 

Dmscr  pyffJUifriDML     cjiosssd  jvxam/dml 

F-/BRES  r/B/tES 

Fig.  /9. — A   Diagram  Designed  by  the  Author  to  Illustrate  the   Effects  of  Cortical 
AND  Non-cortical  Lesions  of  the  Cerebrum. 

It  will  be  perceived  that  the  motor  convolutions  of  the  cortex 
contain  special  centres  of  motion  (6\).  From  these  centres  fibres  of  the 
so-called  '■'■  pyramidal  tracts  "  can  be  traced  through  the  medullary  centre 
of  each  hemisphere  (the  white  matter  of  the  cerel)rum)  to  enter  the  posterior 
half  of  the  internal  capsule  that  passes  between  the  corpus  striatum 
( G.  S.)  and  the  optic  thalamus  (0.  T.).  At  the  level  of  the  base  of  the 
cerebrum  these  fibres  are  continued  downward  successively  through  the 
cms  cerebri,  the  pons  varolii,  the  medulla,  and  into  the  spinal  cord.     At 


256  LECTl  KES    UN    NEliVOUS   DISEASEfci. 

the  lower  iiart  of  the  niediilla  the  {)\  lainidiil  Iriicts  undergo  a  ehange. 
Some  of  the  hbres  (usually  about  10  per  eent.J  pass  down  the  same  side 
of  the  cord  in  Turck's  columns  (see  Fig.  29).  The  remainder  cross  to 
the  opposite  side  of  the  cord  and  compose  the  so-called  crossed  pyramidal 
columns  of  the  cord  (see  Fig.  32). 

Flechsig  has  shown  that  the  percentage  of  crossed  to  direct  pyra- 
midal fibres  varies  in  dilTercnt  individuals.  In  a  few  eases  all  have  been 
observed  to  cross,  and  in  other  instances  all  have  been  seen  to  pass 
directly  into  the  cord  without  decussation.  Both  of  these  conditions, 
however,  must  be  regarded  as  exceptions  to  the  rule.  Cerebral  lesions 
that  induce  hemiplegia  of  the  opposite  side  are  commonly  associated 
with  a  more  oi"  less  extensive  paresis  of  the  same  side,*  on  account  of  the 
direct  pyramidal  fibres.  This  paresis  is,  nevertheless,  overshadowed  by 
the  hemiplegia,  and  is  often  unrecognized  for  that  reason.  In  those  rare 
oases  where  the  hemiplegia  is  upon  the  same  side  as  the  cerebral  lesion 
the  direct  pyramidal  fibres  are  in  excess  of  the  crossed,  if  not  exclusively 
present. 

Surface  hemorrhages  are  sometimes  observed  in  connection  with 
miliary  aneurisms  and  thrombosis  of  the  cerebral  sinuses  and  the 
meningeal  veins ;  also  as  a  result  of  a  collateral  circulation  following 
embolic  occlusion  of  the  middle  cerebral  arter}".  They  may  exist, 
furthermore,  around  localized  morbid  processes,  such  as  foci  of  soften- 
ing, tumors,  abscess,  etc. 

Intra-cerehral  hemorrhcKH'n  may  appear  as  small  spots  of  discolora- 
tion if  due  to  a  rupture  of  the  capillary  vessels;  or,  if  the  ruptured  vessel 
be  a  large  one,  as  clotted  masses  within  the  white  substance  of  the  hemis- 
pheres, the  basal  ganglia,  the  crura  cerebri,  the  pons,  the  cerebellum,  and 
the  medulla.  In  some  cases  the  ventricles  are  more  or  less  filled  with 
blood.  This  is  more  liable  to  occur  when  the  caudate  nuclei  or  the 
thalami  are  iuA'olved. 

The  most  common  seat  of  intra-cerebral  hemorrhage  is  within  the 
substance  of  the  caudate  and  lenticular  nuclei  of  the  corpus  striatum 
and  the  thalamus  of  either  hemispheres.  The  right  side  appears  to  be 
more  frequently  affected  than  the  left,  but  the  relative  proportion  is 
nearly  equal  as  regards  the  ganglia.  The  pons  Varolii  and  cerebellum 
are  often  the  seat  of  clots. 

The  basal  gangliaf  of  the  cerebrum  are  nourished  by  vessels  that  pass 

*The  "direct  pyramidal  fibres  "  (Fig.  19)  usually  disappear  iu  the  middle  dorsal  seg- 
ments. According  to  some  observers  a  certain  proportion  of  these  fibres  cross  in  the  whiti' 
commissure  of  the  cord,  and  after  crossing  become  associated  with  the  cells  of  the  anterior 
horn.  Ferricr  seems  to  incline  toward  the  view  that  this  is  the  rule  rather  than  the 
exception, — a  deduction  which  I  cannot  fully  accept  as  proven. 

t  A  term  applied  to  the  corpora  striata  and  the  optic  thalami  because  they  are  situated 
near  to  the  base  of  the  cerebrum. 


CEKEBEAL    HF:M(  )i;i{HAGE.  257 

from  the  circle  of"  Willis  tliruugli  the  anterior  :uid  j)()sterior  perforated 
spaces.  These  ganglia  lie  in  intimate  relation  with  the  j)aths  of  conduc- 
tion of  motor  and  sensory  imi)ulsos.  Whether  any  of  the  fibres  of  the 
internal  capsule  are  structurally  related  with  the  cells  that  compose  these 
ganglia  is  still  a  disputed  point.  The  later  Investigations  of  Hechsig 
seem  to  disprove  it. 

Clinically  the  question  in  dispute  is  of  no  importance,  because  any 
increase  in  size  of  these  gray  masses  (as  would  occur  from  a  clot  within 
them)  would  inevitably  cause  pressure  to  a  greater  or  less  extent  upon 
the  motor  or  sensory  tracts  of  the  internal  ca])sule.  Fig.  79  will  make 
this  apparent. 

Again  the  caudate  nucleus  of  the  corpus  striatum  and  the  thalamus 
of  each  hemisphere  enter  into  the  formation  of  the  ventricles;*  hence 
any  lesion  of  these  ganglia  would  be  liable  to  displace  cerebro-spinal 
fluid.  Such  a  displacement  is  believed  by  Duret  to  account  for  the  loss 
of  consciousness  that  usually  accompanies  attacks  of  intracerebral 
hemorrhage. 

Again,  certain  fibres  associated  with  the  special  senses  of  smell, 
sight,  hearing,  taste,  and  tactile  sensibility  run  in  the  internal  capsule 
and  are  liable  to  be  destroyed  by  clots  within  the  basal  ganglia  of  the 
cerebrum. 

The  method  of  recovery  from  an  extravasation  of  blood  into  the 
brain-substance  is  as  follows:  1.  the  clot  generally  becomes  encapsu- 
lated by  the  formation  of  a  false  membrane;  2.  a  serous  exudation  com- 
bined with  fatty  metamorphosis  softens  and  dissolves  the  clot  and  the 
debris  of  brain-tissue,  and  changes  them  into  a  yellowish  Iluid  ;  3,  bands  of 
connective  tissue  form  from  the  sides  of  the  cyst  so  produced  and  traverse 
it  in  all  directions;  4,  after  a  lapse  of  time  these  connective-tissue  bands 
contract  and  draw  the  sides  of  the  cyst  in  apposition,  the  fiuid  contents 
becoming  absorbed  to  a  greater  or  less  extent ;  5,  a  stellate  and  pig- 
mented cicatrix  often  forms.  Apoplectic  cysts  are  formed,  as  a  rule,  in 
about  two  months  after  the  hemorrhage,  in  favorable  cases. 

I  have  already  referred  to  the  fact  that  secondary  changes  in  nutri- 
tion are  observed,  in  the  case  of  destruction  of  the  cortical  cells,  when 
the  motor  fibres  are  destroyed  by  intra-cerebral  clots.  We  owe  to  Tiirck 
our  first  intimation  of  these  secondary  sclerotic  and  degenerative  changes 
in  nerve-fibres.  His  discovery ,f  which  was  for  a  time  buried  in  the 
archives  of  the  Vienna  Academj^  of  Sciences,  has  proved  of  inestimable 
benefit  to  anatomists,  since  it  enables  them  to  trace  the  course  of  special 

*  Wilder  doubts  if  the  thalamus  actually  forms  a  part  of  the  Hoor  of  the  corresponding 
lateral  ventricle. 

t  A  paper  read  in  1851  upon  the  results  of  pathological  observation  respecting  the 
results  of  old  cerebral  lesions. 


258 


LECTUKES   ON    NJSKVOUS   DISEASES. 


l)iiii(lk"s  of  lihi-cs  witliiii  the  substance  of  the  brain  and  spinal  cord.  Tlie 
degenerated  fibres  become  ver}'  distinctl}'  outlined  from  tlie  healthy 
fibres   in  ail  transverse  sections  of  the  nerve-centres,  and  thus  Nature 


l^'^N. 


AlEDULLfi 


KiG.  80. — A  Di.\GKA.MM.\Tic  Repkesentation  Designed  to  Show  ihe  Course  of  the 
Motor  Tracts  and  the  Effects  of  Lesions  of  the  C'rus  Cerebki,  Pons  Varolii,  and 
Medulla  Oblongata  upon  Motility.  (Modified  from  Starr  by  the  Author.)  The 
ted  fibres  represent  the  motor  fibres  which  govern  facial  movements  These  decussate  in 
the  middle  of  the  pons.  The  blue  fibrfs  are  connected  with  tongue  movements.  These 
decussate  at  a  lower  level  in  the  pons.  The purj>le Jibres  arethe  motor  tracts,  which  preside 
over  voluntary  movements  of  the  arms  and  legs.  Some  of  these  decussate  at  the  lower  level 
of  the  medulla  (the  "  crossed  pyramidal  tracts"),  while  others  do  not  decussate  (the  "direct 
pyramidal  tracts"). 

Each  of  these  three  bundles  of  fibres  are  associated  with  a  t^roup  of  motor  cells  after 
leaving  the  crus.  The  facial  fibres  terminate  in  the  facial  nuclei  (f.  «.);  the  tongue  fibres 
in  the  hypoglossal  nuclei  (/;;.  «.);  the  pyramidal  tracts  in  the  cells  of  the  anterior  horns  of 
the  spinal  gray  matter  (s.  c). 

A  lesion  at  1  and  2  might  affect  any  of  these  tracts  .separately,  or  various  combinations  of 
the  three  might  e.\ist,  and  manifest  its  presence  by  a  disturbance  of  motility  without  affect- 
ing the  sensibility  of  any  part  to  imoressions  of  touch,  pain  or  temperature.  If  the  tongue, 
face  or  limbs  were  paralyzed  by  such  a  lesion  the  parts  would  be  deprived  of  motility  upon 
the  same  side, — that  opposed  to  the  .seat  of  the  lesion. 

A  lesion  at  3  would  causeyVtc/rt/  diplegia.  This  is  at  the  middle  level  of  the  pons,— at 
the  raphse. 

A  lesion  at  4  would  cause  hypoglossal  paralysis  and  hemiplegia  of  the  opposed  side. 

A  lesion  at  :>  would  cause  bilateral  paralysis  of  the  tongue. 

A  lesion  at  6  would  cause  motor  paresis  op  both  arms  and  legs,  rather  than  .a  complete 
paralysis  of  motion.  The  non-decussating  pvramidal  fibres  would  still  be  unimpaired  : 
hence  some  voluntary  movements  would  be  unaftected  by  the  lesion. 

Paralysis  of  the  tongue,  if  imilatpral,  causes  the  tongue  to  deflect  toward  the  paralyzed 
side  when  protruded,  if  bil.ateral  protrusion  of  the  tongue  becomes  impossible,  and  chewing, 
swallowing,  and  talking  become  >eiy  difficult. 


CEREBRAL   HEMORRHAGE. 


259 


perfects  a  dissection  that  no  liumaii  hand  could  possibly  make.     We 
have  been  enabled  to  nc(iuiiv  of  lute  many  fncts  in   anatomy  wiiich  aid 


-^^A^^o.S-"* 


i?-  N<-^  ^ 


4ks^' 


SS'A/^ 


2f/f 


SPJHML  CORD 


Fig.  81. — A  Diagrammatic  Representation  of  the  Course  of  the  Sensory  Tracts,  and 
THE  Effects  of  Lesions  involvin(;  the  same  within  the  Ckus  Cerebri  and  the 
Medulla  Oblongata.  (Modified  from  Starr  by  the  Author.)  The  red  fibres  represent 
the  sensory  fibres  of  the  face  which  pass  to  the  cerebral  hemispheres  by  means  of  the 
pons  and  crus.  They  spring  from  two  sets  of  nuclei  (V'n  and  Vn').  The  purple  fibres  repre- 
sent the  tracts  for  the  "  muscular  sense."  The  blue  fibres  represent  the  tracts  for  the  trans- 
mission of  impressions  of  touch,  pain,  and  temperature.  The  arrows  indicate  the  direction 
of  the  impulses  carried  by  each  set. 

A  lesion  at  1  (tegmentum  of  the  crus  crupper  part  of  the  pons  Varolii)  would  cause /;<?/«/- 
ancrsthesia  of  the  opfiosite  side  of  the /ace,  and  also  of  the  op/>osed  limbs,  and  tJie  opposed 
side  of  the  trunk.  The  muscular  sense  might  also  be  disturbed  on  the  opposed  lateral  half 
of  the  body. 

A  lesion  at  2  or  3  (the  lower  part  of  pons  in  the  formatio-reticularis  or  in  the  medulla) 
would  cause  crossed  heiniantesthesia,  the  face  being  affected  upon  the  side  corresponding 
to  the  seat  of  the  lesion,  and  the  body  and  limbs  upon  the  side  opposed  to  the  lesion.  This 
statement  holds  true  to  all  lesions  which  affect  the  tract  below  the  point  of  decussation  of  the 
trigeminal  fibres,  viz.,  at  the  middle  level  of  the  pons. 

US  directly  in  determining  the  seat  of  localized  lesions  during  life.    Many 
of  these  have  been  mentioned  in  the  first  section  of  this  volume.     The 


2H0  LECTURES    OX    NEIIVOIS    DISEASES. 

mt'tliods  of  rcst'iirc'li  brought  to  professional  notice  by  Tiirc-k.  Flechsig, 
Guclden,  Fritseh,  Witsig,  and  others  have  been  of  inestimable  value  in 
the  study  of  neuro-anatomy  and  neuro-physiolog}'. 

ApopU'etic  clots  ma}'  assume  two  forms:  (1)  those  where  the  blood 
is  collected  into  a  circumscribed  mass,  a  so-called  ''  apoplectic  focus," 
and  (2)  those  where  minute  points  of  capillary  extravasation  are  alone 
detected. 

Apo])lectic  foci  vary  in  size  fi'om  that  of  a  small  jjea  to  that  of  a 
large  orange.  They  are  commonly  of  the  size  of  a  hazel-nut,  and  are 
usually  more  or  less  globular  in  form.  When  blood  is  extravasated 
"upon  the  surface  of  the  cerebral  hemispheres  or  into  the  substance  of 
the  pons,  the  clot  generallj'^  assumes  the  form  of  a  disseminated  layer 
rather  than  a  circumscribed  mass.  The  number  of  foci  that  develop 
simultaneously  is  apt  to  vary.  Not  infrequently  homologous  regions  in 
each  hemisphere  are  attacked  at  the  same  time.  Although  it  is  the  rule 
to  encounter  a  single  focus,  several  may  exist  in  different  parts  of  a  brain 
and  give  unmistakable  evidences  of  a  simultaneous  formation. 

Respecting  t!he  relative  frequency  of  clots  in  different  parts  of  the 
cerebrum,  Andral  reports  386  cases,  in  which  he  found  that  the  corpus 
striatum  was  involved  in  61,  the  optic  thalamus  in  35,  the  centrum  ovale  in 
27.  and  the  centrum  ovale  and  basal  ganglia  combined  in  202.  Rosen- 
thal gives  tlu'  statistics  of  103  autopsies  at  the  Vienna  General  Hospital, 
which  show  that  the  caudate  nucleus  alone  was  involved  in  32  cases, 
the  lenticular  in  20,  both  nuclei  of  the  corpus  striatum  in  8,  the  caudate 
nucleus  and  the  thalamus  in  7,  the  ojjtic  thalamus  alone  in  20.  centrum 
ovale  in  3,  parietal  liil)e  in  2,  lenticular  nucleus  and  other  parts  in  6.  tiie 
basal  ganglia  of  the  two  sides  in  2.  It  thus  appears  that  the  lenticular 
and  caudate  nuclei  of  the  corpus  striatum  were  attacked  in  a  very  large 
percentage  of  all  the  cases,  and  that  the  thalamus  ranks  as  the  next  most 
freipient  seat  of  apoi)lectic  foci. 

Etiology. —  Vascular  changes,  in  the  vast  majority  of  subjects,  have 
preceded  a  riq)ture  of  the  cerebral  vessels,  unless  it  be  dependent  upon 
traumatism.  Among  the  conditions  that  tend  toward  rupture,  miliary 
aneurisms,  atheroma,  and  fatty  degeneration  of  the  vessels  stand  fore- 
most. The  various  causes  of  cerebral  thrombosis  and  embolism  may 
also  indirectly  produce  a  hemorrhage.  These  have  Ikhmi  discussed  in 
previous  pages. 

Degenerations  of  the  brain-substance  may  have  preceded  the  rupture 
of  vessels.  We  not  infrecjuently  encounter  sudden  paralytic  symptoms 
in  connection  with  softening  of  the  brain.  In  such  cases,  the  softening 
is  accompanied  l)y  secondary  hemorrhage. 

Certain  diseased  conditions  of  the  organs  and  tissues  may  be  factors 
in  producing  apopli'ctic  extravasations.     Among  these  may  be  mentioned 


CEEEBiiAL    HEMOliliHAGE.  261 

(1)  simple  Inpertropliy  of  the  left  ventriele;  {2)  valvular  lesions  of  llie 
heart;  (3)  chronic  nephritis,  which  induces  changes  in  the  coats  of  blood- 
vessels; (4)  a  congenital  delect  in  the  construction  of  the  arterial  coats 
or  miliary  aneurisms;  (5)  compression  of  the  jugular  veins  or  the  supe- 
rior caAa  from  tumors,  aneurism,  etc.;  (6)  certain  abnormal  blood-con- 
ditions (chlorosis,  scurvy,  syphilis,  typhus,  gout,  chronic  alcoholism, 
Bright's  disease,  rheumatism,  etc.). 

Statistics  show  that  age  exerts  a  marked  influence  ui)on  the  develop- 
ment of  apoplex}'.  I'he  percentage  increases  gradually  from  the  age  of 
twenty  to  sixt}'.*  It  is  rare  before  twent}^  except  in  infancy.  After  the 
Hftieth  year  the  relative  percentage  becomes  ver^-  large. 

For  some  unexplained  reason,  a  large  proportion  of  cases  are  attacked 
between  the  hours  of  three  to  live  in  the  afternoon,  and  two  to  four  in 
the  morning.  Males  are  more  commonly  attacked  than  females.  The 
cold  seasons  of  the  year  seem  to  be  especially  liable  to  induce  cerebral 
hemorrhage.  The  so-called  plethoric  habit  has  little,  if  anything,  to  do 
with  apoplectic  seizures. 

Among  the  excifim/  causes  of  cerebral  ai)oplexy  may  be  mentioned 
all  mental  or  physical  conditions  which  tend  to  increase  the  heart's 
action  or  to  suddenly  intensify  the  blood-pressure. 

Attacks  of  coughing  or  laughing;  severe  physical  exercise;  straining 
at  stool;  over-indulgence  in  alcohol;  sudden  rage,  grief,  or  mental  excite- 
ment ;  the  sexual  act ;  a  recumbent  position  of  the  head  ;  the  eating  of  a 
hearty  meal;  the  use  of  opium;  a  cold  bath;  and  many  other  similar 
occurrences  have  been  reported  factors  in  producing  a  rupture  of  an 
arter\-  whose  walls  have  been  impaired  by  the  predisposing  causes 
mentioned. 

Symptoms. — Prodromal  symptoms  indicative  of  cerebral  irritation 
are  frequent  in  subjects  inclined  toward  apoplectic  attacks. 

A  headache  of  a  dull  and  ill-defined  character  is  often  present  on 
rising.  Insomnia  may  have  existed  for  some  time.  Vertigo  may  have 
been  often  noticed.  The  intellectual  faculties  are  sometimes  impaired  to 
a  greater  or  less  extent.  There  may  he  flushing  or  pallor  of  the  face, 
bleeding  from  the  nose,  ringing  in  the  ears,  persistent  specks  before  the 
eyes.f  nausea  or  vomiting,  irritability  of  temper,  a  sense  of  weight  or  of 
numlmess  in  the  limbs,  transient  disturbance  of  speech,  tremor  of  the 
muscles,  and  disseminated  pains  of  a  neuralgic  type.  I  regard  epistaxis 
in  old  subjects  as  a  symptom  of  cA'il  import,  as  a  rule.  If  it  accompanies 
the  other  prodromal  phenomena  of  apoplexy  it  is  particularly  ominous. 

*  Loomis  states  that  the  increase  of  percentage  never  stops,  and  that  the  small  number 
of  persons  who  live  after  seventy  years  is  not  taken  into  the  computation  by  those  who 
limit  the  danger. 

t  These  may  be  due  to  small  extravasations  into  the  retina. 


262  LECTUKES    ON    NEKVOIS    DISEASES. 

It  should  be  borne  in  iiiiiid  lliat  upopU-etie  iittiiekB  may  often  occur 
without  any  of  the  prodromal  synipLonis  enumerated.  On  the  other 
hand,  it  often  happens  that  some  of  them  have  been  persistent  for  a 
greater  or  less  period  of  time.  The  evidence  drawn  from  statistics 
regarding  the  prodromata  of  apoplexy  are,  to  mj^  mind,  of  little  value  as 
a  basis  of  diagnosis.  Vertigo,  epistaxis,  headache,  muscie  volitantes, 
change  in  the  disposition,  a  sense  of  weight  or  numbness  in  the  limbs, 
drowsiness,  lethargy,  etc.,  do  not  justify  in  every  case  the  alarm  which  a 
diagnosis  of  a  liability  to  an  apoplectic  attack  would  necessarily  create 
in  a  patient.  1  regard  attacks  of  thickness  of  speech,  slight  paralyses 
of  short  duration,  double  vision  from  paresis  of  the  ocular  muscles,  etc., 
as  possessing  greater  clinical  significance  than  the  others  ;  but  even  these 
may  be  due  to  vascular  disturbances  which  are  not  always  followed  b}' 
cerebral  hemorrhage.  A  ph3-sician  cannot  he  too  careful  in  expressing 
an  opinion  calculated  to  excite  anxiety  and  ahum  either  in  the  mind  of  a 
patient  or  interested  friends  until  the  examination  warrants  a  positive 
diagnosis. 

The  actual  symptoms  of  "  apoplectic  stroke,"  as  it  is  commonly 
called,  will  be  modified  (1)  by  the  amount  of  blood  that  escapes,  (2)  by 
the  damage  that  it  causes  to  the  brain-cells  or  nerve-fibres,  and  (3)  by  the 
seat  of  the  clot. 

The  onset  of  an  apoplectic  attack  may  be  sudden  or  gradual.  The 
situation  of  the  clot  and  its  size  will  determine  the  character  of  the 
initial  symptoms.  Clots  in  the  medulla,  pons,  or  cerebellum  are  liable 
to  fell  the  patient  to  the  ground  without  warning,  as  if  struck  by  a  blow, 
even  if  the  hemorrhage  be  small.  A  hemorrhage  into  the  ventricles  may 
do  the  sanie,  and,  if  extensive,  may  sometimes  produce  instantaneous 
death.  These  cases  do  not  produce  the  typical  form  of  attack,  however, 
because  they  are  less  frequent  than  those  where  the  hemorrhage  occurs 
in  or  ui)on  the  cerebral  hemispheres.  In  many  instances  the  coma  comes 
on  gradually,  and  is  preceded  by  pain  in  the  head,  nausea,  confusion  of 
the  intellect,  dizziness,  incoherent  speech,  and  other  of  the  prodromata 
enumerated  in  preceding  pages.  Occasionally  the  attack  is  ushered  in  by 
clonic  convulsions,  or  by  a  paralysis  of  the  arm,  leg,  face,  eye,  or  some 
other  part.  I  recall  a  case  where  one  of  my  patients  was  seized  with  a 
weakness  of  the  leg,  which  was  followed  by  paresis  of  the  arm,  then  by 
complete  paralysis  of  tiiat  side,  then  by  stupor  which  deepened  rapidly 
into  coma,  and  finall}'  by  convulsions  before  death  ensued.  I  haA'e  met 
cases  where  coma  did  not  occur  throughout  the  attack.  Trousseau, 
Andral,  and  others  report  similar  instauees. 

The  coma  of  apoplexy  generally  becomes  profound,  and  lasts  for 
hours  or  even  days.  The  muscles  are  relaxed,  the  face  is  usually  red  or 
cyanotic,  the  abolition  of  consciousness  is  complete,  the  head  and  eyes 


CEREBRAL   HEMORRHAGE.  263 

may  1ie  rotated  to  one  side,  the  pupils  are  apt  to  be  irregular,  the  tem- 
perature of  the  body  falls  to  about  90.5°,  the  breathing  may  be  reguhir 
and  quiet,  or  it  may  be  stertorous;  finally,  the  urine  and  feces  may  be 
passed  involuntarily. 

Although  many  theories  have  been  advanced  to  explain  the  mechan- 
ism of  apoplectic  attacks,  I  believe  that  all  may  be  interpreted  as  result- 
ing from  the  following  conditions:  (1)  from  the  disturbance  that  the 
lesion  has  created  upon  the  intracranial  circulation  directly  by  pressure; 
(2)  from  the  displacement  of  cerebro-spinal  fluid  from  the  ventricles  or 
the  cranial  cavity,  thus  disturbing  the  circulation  of  the  organ  in  an  indi- 
rect way;  (3)  from  an  increase  of  intra-cerebral  pressure;  and  (4)  from 
direct  injury  done  to  the  nervous  elements,  and  the  irritation  of  sur- 
rounding parts. 

Respecting  the  duration  of  life  in  severe  cases,  Aljererombie  reports 
an  instance  where  death  occurred  in  live  minutes  after  tlie  attack;  1)iit, 
as  a  rule,  it  seldom  occurs  before  two  or  three  hours,  and  it  may  be  de- 
layed for  one  or  two  days.  Prolonged  coma  may  induce  pulmonary 
oedema,  and  lesions  of  the  medulla  or  pons  may  interfere  with  the  vagus 
nerve,  and  thus  produce  death.  I  have  never  observed  a  case  of  recovery 
where  the  coma  has  lasted  more  than  two  days.  A  very  marked  rise  in 
temperature  above  the  normal  point  is  a  very  serious  omen. 

In  favorable  cases,  consciousness  is  regained  gradually  after  a  short 
interval  of  coma,  which  has  lasted  for  only  a  few  hours.  The  reflex  ex- 
citability of  the  limbs  usually  returns  before  consciousness,  as  detected 
by  irritating  the  skin  Avith  a  pin  or  by  tickling  the  soles  of  the  feet.  The 
temperature  of  the  body  returns  to  the  normal  standard.  After  the  pa- 
tient begins  to  exhibit  evidences  of  consciousness,  a  sense  of  pain  in  the 
head  and  of  general  discomfort  is  complained  of;  tlie  answers  to  ques- 
tions are  inappropriate,  or  badly  articulated  ;■  a  drowsy  condition  per- 
sists; the  patient  is  apt  to  be  apathetic,  peevish,  or  surly;  the  movements 
of  the  muscles  not  paralyzed  are  feeble  ;  and,  in  some  cases,  delirium  may 
be  developed.  We  are  apt  to  encounter  a  rise  of  temperature  on  the 
second,  third,  or  fourth  day,  and  other  febrile  manifestations.  Pain  in 
the  paralyzed  limbs  is  frequently  complained  of  by  these  patients.  The 
emotions  are  not  well  controlled.  The  appetite  and  the  habit  of  normal 
'Sleep  is  not  usually  regained  for  some  months.  Whenever  cerebritis  is  to 
follow,  the  symptoms  of  that  affection  will  usually  be  developed  by  the 
beginning  of  the  second  week. 

In  order  to  interpret  the  more  common  symptoms,  some  knowledge 
must  be  had  of  the  functions  of  the  component  parts  of  the  brain  and 
the  course  of  the  more  important  tracts  of  fibres.  A  close  study  of 
Figs.  3  and  5  will  aid  the  reader  in  appreciating  the  results  of  cortical 
lesions.     Subsequent   diagrams  will    help   to   interpret   the   results    of 


264  LECTUKES   OX   NERVOUS   DISEASES, 

l)rossurc  upon  \\\v  lilircs  of  t lie  iutcnial  cnpsiilc.  Lesions  of  the  l):isal 
ganiiliii,  the  cni«  cerel)ri,  tlie  pons,  the  cerebelluni,  iind  the  meduUu  liuve 
already  been  considered  separately  in  this  volume. 

It  may  assist  tiie  reader  if  we  stai't  with  the  statement  that  the  ex- 
istence of  suddenly-developed  lesions  within  the  cranial  cavity  may  he 
indicated  by  some  or  all  of  the  following  symptoms  : — 

1.  Motor  J'akakvsks,  which  will   vary  in  its  extent,  duration,  and 

degree. 

2.  Sensory  Paralysis,  which  will  vary  in  its  extent,  duration,  and 

degree. 

3.  Disturbances  of  Consciousness. 

4.  Disturbances  of  the  Special  Senses. 

5.  Abnormal  Attitude  of  the  Head  and  Eyes. 

().  Tremor,  which  may  present  one  of  several  forms. 

7.  Changes  in  the  Pupils,  Pulse,  Temperature,  and  Respiration. 

8.  Abnormal  Phenomena  of  the  Bladder,  Rectum,  Kidney,  etc 

9.  Mental  Impairment. 

In  the  first  section  of  this  work,  attention  has  been  called  to  some 
of  these  symptoms.  It  is  not  necessary  to  repeat  them  here.  A  few  of 
the  more  important  facts  may,  however,  be  summarized. 

Cerebral  lesions  which  affect  the  motor  convolutions  or  the  fibres 
that  spring  from  them  induce  either  a  monoplegia  or  a  hcmiplec/ia  of  the 
opposite  side. 

The  duration  and  degree  of  the  paralysis  will  aid  in  determining  the 
seA'erity  of  the  structural  changes  that  the  lesion  has  produced.  Paraly- 
sis of  motion  may  be  rect)gnized,  even  when  profound  coma  exists,  by 
tests  that  have  been  mentioned  in  previous  pages. 

Ifaliml>  is  paralyzed  it  will  drop  inertly  if  raised.  Tickling  the 
soles  of  the  feet  will  often  cause  the  patient,  even  when  partially  coma- 
tose, to  draw  up  the  lower  limbs  when  not  paral3zed.  If  this  fail,  painful 
impressions,  as  a  ])in  thrust,  will  usually  create  sluggish  movements  in 
comatose  subjects  if  i)aralysis  be  absent. 

Monoplegia,  or  that  form  of  paralysis  in  which  a  distinct  groui»  of 
muscles  is  paralyzed,  indicates  a  circumscribed  lesion  that  impaira  the 
free  action  of  those  cortical  motor  centres  which  preside  over  the  mus- 
cles affected.  The  tvpe  is  a  guide  to  the  seat  and  extent  of  the  lesion 
(Fig.  3). 

A  monoplegia  may  usually  be  diagnosed  from  paralysis  of  a  spinal 
nerve  by  the  fact  that  the  muscles  paralj^zed  are  not  supplied  by  one 
nerve. 

We  encounter  the  crural  type  ol"  monoplegia  when  the  superior 
parietal  convolution  of  the  opposite  cerebral  hemisphere  is  the  seat  of  the 


CEREBKAL   HEMOEEHAGE.  2G5 

l('si(Mi,  the  brarhidl  ti//ie  in  lesions  of  tlie  n[)i)er  part  of  the.  ascending 
frontal  and  the  base  of  the  first  and  second  frontal  gyri,*  and  the /acta/ 
/i/pe  when  the  middle  of  the  ascending  frontal  convolntion  is  involved. 
Lesions  of  the  ascending  parietal  convolution  are  apt  to  produce  a  mono- 
p/egia  of  the  hand.  The  coordinated  movements  of  speech  become 
affected  (a/;/(a«m  of  the  motor  type)  when  the  base  of  third  frontal  gyrus, 
the  island  of  Reil,  or  the  medullary  substance  which  carries  the  fibres 
connected  with  the  cells  of  these  regions,  are  atlected  bj'  the  lesion. 
Figs.  3  and  24  will  explain  these  deductions,  and  pages  50  and  51  relate 
to  this  subject  more  fully  than  is  deemed  wise  here.  The  late  views  of 
Horsley  are  there  reviewed. 

Hemiplegia,  or  paralysis  of  one  lateral  half  of  the  body,  may  indi- 
cate a  lesion  either  of  the  brain  or  of  the  spinal  cord. 

If  of  cerebral  origin,  the  lesion  must  atfect  the  greater  part  of  the 
fibres  which  compose  the  pyramidal  tract  of  the  opposite  side  (Fig.  29); 
hence  it  is  seldom  cortical,  as  it  would  haA'e  to  be  sufficiently  large  to 
destroy  the  function  of  the  entire  motor  area.  As  a  rule  the  lesion  is 
confined  either  to  the  white  substance  of  one  cerebral  hemisphere,  the 
basal  ganglia,  the  internal  capsule,  the  motor  bundles  of  the  cms  and 
l)ons,  or  the  anterior  p3-ramids  of  the  medulla. 

If  the  hemiplegia  be  of  spinal  origin,  the  lesion  must  be  situated 
high  up  in  the  cord  (above  the  origin  of  the  nerves  to  the  upper  ex- 
tremity) and  exert  its  effects  upon  the  lateral  half  of  the  cord  that  cor- 
responds to  the  motor  paralysis. 

In  the  first  section  of  this  work  the  varieties  of  motor  paralysis 
have  already  been  discussed  in  a  general  way.  Later  in  this  volume,  the 
special  types  will  be  given  further  consideration.  It  may  be  well  to  give 
here,  as  an  aid  to  the  study  of  the  various  types,  a  few  of  the  clinical  facts 
that  will  prove  of  aid  in  diagnosis : — 

1.  Cerebral  paralyses  occur  chiefly  on  the  oppof^ed  side  of  the  body 
1)elow  the  head.     This  is  true  of  both  motor  and  sensory  paralyses. 

2.  Motor  paralj'sis  of  cerebral  origin  is  liable  to  be  associated  icith 
more  or  less  disturbance  of  sensation  when  the  lesion  is  non-cortical. 
This  is  not  the  case,  as  a  rule,  when  the  lesion  is  situated  upon  the  sur- 
face of  the  brain. 

3.  When  sensorij  and  motor  parali/ses  coexist,  as  a  result  of  a  cerebral 
lesion,  they  are  upon  the  same  side;  the  reverse  is  true  of  spinal  lesions. 

4.  Lesions  within  the  cranium,  which  cross  the  mesial  line,  are  liable 
to  produce  paralysis  upon  both  sides  of  the  body. 

5.  Lesions  of  the  base  of  the  brain  are  more  liable  to  produce  paral- 
yses of  cranial  nerves  than  are  those  of  the  hemispheres  or  basal  ganglia. 
Vomiting  and  choked  disk  are  also  frequently  observed  in  these  cases. 

*  The  term  "  gyrus  "  is  synonymous  with  "  convolution." 


266  LECTUKEH   ON    NEKVOUS    DISEASES. 

6.  The  sensory  areas  of  the  cortex  commonly  give  rise  (when  circum- 
scribed lesions  tend  to  im])air  or  destroy'  their  functions)  to  disturlnuices 
of  vision,  hearing,  smell,  or  touch.  If  the  lesion  be  very  extensive,  hemi- 
anesthesia nia}^  be  produced.  Munk,  Tripier,  and  Moeli  have  lately 
shown  that  the  cortex  of  the  entire  motor  area,  as  well  as  the  remaininu 
parietal  convolutions,  must  be  destroyed  in  animals  to  produce  complete 
hemianesthesia.     Hence  it  is  seldom  of  cortical  origin. 

7.  Gonsciouaness  is  not  usuallj^  lost,  at  the  time  of  the  attack,  with 
purely  cortical  lesions.  Apparent  exceptions  to  this  statement  occur;  but 
they  are  to  be  attributed  to  eft'ects  exerted  by  the  lesion  upon  deeper  parts. 

8.  Einleptic  cUtdvhii  (which  are  characterized  by  the  dcA-elopment 
of  paralysis  of  a  transient  character  after  the  fit)  indicate  an  irritation 
of  the  cortical  motor  centres  by  the  lesion.  This  symptom  is  often  spoken 
of  as  "  Jacksonian  epilepsy,"  being  named  after  the  autiior  wlio  first  inter- 
lu'eted  its  phenomena  correctly  (Hughlings-Jackson). 

Cortical  Cerebral  Lesions  may  be  indicated  (1)  by  monoplegia 
of  the  opposite  side;  (2)  by  disturl)ances  of  some  special  sense;  (3)  by 
the  presence  of  consciousness  at  the  time  of  the  attack;  (4)  by  an 
early  rigidity  of  the  paralyzed  muscles;  (.5)  by  circumscribed  pain  at  the 
seat  of  the  lesion,  which  may  be  elicited  or  increased  b}'  percussion  over 
the  lesion;  and  (G)  possibly  by  Jacksonian  epileps}',  if  the  lesion  creates 
simply  an  irritation  of  the  cells  of  the  cortex. 

Wlien  sensory  and  motor  disturbances  coexist  with  a  pureh'  cortical 
lesion  it  indicates  that  tlie  lesion  involves  both  the  motor  and  sensory 
areas  of  the  cortex.  Trephining  would  be  contra-indicated  in  such  a 
case,  because  the  lesion  is  of  necessity  diffused  over  a  large  area.  The 
existence  of  a  well-defined  traumatic  monoplegia  without  sensory  com- 
plications is  an  indication  for  immediate  surgical  interference,  provided 
that  the  paralysis  is  on  the  side  opposed  to  the  injury.  The  situation 
of  the  cortical  motor  centres  are  of  assistance  also  in  determining  the 
seat  at  which  to  trephine  for  circumscribed  lesions  within  the  skull  that 
are  not  of  a  traumatic  character. 

The  convolutions  o^WiQ  frontal  lobes  are  not  associated  with  motion, 
excepting  the  ascending,  and  the  bases  of  the  first,  second,  and  third 
frontal  convolutions.  Outside  of  this  area  lesions  of  the  frontal  lobe 
apparently  produce  no  symptoms.  If  Broca's  centre  be  destroyed,  motor 
aphasia  follows. 

Irritative  lesions  of  the  occipital  convolutions  sometimes  tend  to 
produce  colored  perception  of  objects  and  other  ocular  spectra.  The 
power  of  vision,  as  well  as  the  memory  of  past  visual  impressions,  seems 
to  be  markedly  imi)nired  by  lesions  of  this  lobe. 

The  convolutions  of  the  temporal  lobe  are  associated  wnth  the 
special  senses  of  smell  and  hearing.     Some  cases  of  aphasia  have  been 


CEKEBKAL   HEMORRHAGE.  '2iu 

induced  also  by  lesions  ol"  this  lobe, — the  so-ctiUed  cases  of  "  word- 
deafness." 

Our  ability  to  localize  lesions  of  the  sensory  regions  of  tlie  liraiii  is 
less  positive  than  of  the  motor  area. 

The  parietal  lube  is  ph3^siologically  associated  with  tlie  tactile  sense, 
as  tar  as  we  are  able  to  judge  by  well -reported  cases. 

Cortical  paralysis  ma}'  often  be  transitory,  if  the  lesion  be  slight  and 
superficial;  or  it  may  he  permanent,  if  deep  and  impinging  upon  the  me- 
dulla oblongata. 

Secondary  degeneration  appears  to  follow  destruction  onh^  of  the 
convolutions  of  the  motor  area  and  the  para-central  lobule. 

Intra-cerebral  Lesions. — We  are  now  prepared  to  discuss  the 
effects  of  intra-cerebral  hemorrhage. 

It  may  be  well  to  preface  our  remark  upon  tliis  liead  by  the  general 
statement  that  such  lesions  may  l)e  accompanied  by  profound  motor 
paralysis  (usually  of  tiie  hemiplegic  type) ;  a  loss  of  consciousness,  as  a 
rule,  at  the  time  of  the  attack;  simultaneous  paral3'sis  of  sensation  (more 
or  less  marked) ;  marked  disturbances  of  some  or  all  of  the  special 
senses,  and  late  rigidit}'  of  the  paralyzed  muscles.  These  sj'mptoms  are 
indicative  of  lesions  within  the  substance  of  the  cerebrum  ratiier  than 
upon  its  surface. 

Some  of  these  sjnuptoms  (especiall}-  hemiplegia,  hemianaisthesia, 
hemianopsia,  loss  of  consciousness,  and  impairment  of  the  special  senses) 
have  been  discussed  in  the  first  section  of  this  volume.  The  reader  will 
find  Figs.  6,  21,  and  36  of  assistance  in  following  the  deductions  given. 

A  few  facts  may  be  given  here  as  a  summary  of  previous  pages  with 
possil)le  advantage. 

Hemiplegia. — A  paralysis  of  the  lateral  half  of  the  body  may  occur 
in  connection  with  lesions  of  the  cerebral  hemisphere.  If  this  form  of 
motor  disturbance  coexist  with  a  slight  or  severe  impairment  of  senf<ation 
upon  the  same  side,  the  existence  of  an  intra-cerebral  lesion  may  be 
strongly  suspected. 

This  combination  is  to  be  attributed  to  pressure  upon  the  tract  of 
fibres  known  as  the  '■^internal  capsule''^  of  the  cerebrum;  because  the 
fibres  of  the  middle  part  of  this  tract  are  motor,  while  those  of  the  pos- 
terior one-third  are  sensory  in  function.  Both  the  motor  and  sensory 
fibres  of  this  tract  decussate  in  order  to  supply  that  lateral  half  of  the 
body  which  is  opposed  to  the  cerebral  hemisphere  through  which  the}' 
pass. 

The  situation  of  the  internal  capsule  can  be  made  clear  to  the  reader 
by  a  diagram  (see  Fig.  82).  Let  us  suppose  a  section  to  be  made  from 
the  forehead  to  the  occiput  at  such  a  level  as  to  intersect  the  masses  of 
gray  substance  buried  within  the  cerebral  hemispheres,  and  known  as  the 


2()8 


LECTURES   ON    NERVOUS   DISEASES. 


"l)usal  g:uij2;lia.'"  We  encounter  in  such  a  section  three  prominent 
masses  of  gray  substance  in  each  hemisphere, — the  caudate  nucleus,  the 
lenticular  nucleus,  and  the  optic  thalamus.  The  caudate  jind  lenticular 
nuclei  are  but  halves  of  tlie  same  body — the  corpus  striatum — which  are 
separated  in  the  plane  of  the  sections  by  fibres  of  the  internal  capsule. 
Tlie  optic  thalami  are  united  to  each  other  by  the  gray  commissure 
which  crosses  the  mesial  line  of  the  brain.  This  is  not  shown  in  the  cut. 
Xow,to  understand  this  diagram,  let  us  suppose  that  a  mass  of  fibres 
like  hairs  are  thrust  vertically  to  the  plane  of  the  section  between  the 


Fig.  82. — A  Diagram  designed  by  the  Author  to   Illustrate  a  Horizontal  Section 

THROUGH   THE   CeKEBRAL    HEMISPHERES   AND   THE   BaSAL    GaNGLIA,  SHOWING   THE   "  In. 

TERNAL  Capsule"  of  the  Cekebkum — The  lettering  of  the  figure  will  be  explained  in 
the  text.  It  may  be  rem.irked  here  that  similar  .subdivisions  of  the  internal  capsule  exist 
in  the  left  half  as  schematically  depicted  in  the  right  half  of  the  figure.  Some  of  the  state- 
ments made  with  reference  to  the  subdivisions  of  the  internal  capsule  are  not  to  be  considered 
as  incapable  of  modification  by  the  results  of  subsequent  research.  The  bend  observed  in 
the  internal  capsule  is  termed  "the  knee"  of  the  capsule.  a,  the  so-called  "caudo- 
lenticular"  portion  of  the  capsule;  y",  }>i,  s,  st.  and  o,  constitute  collectively  the  so-called 
"  thalamo-lenticular"  portion  of  the  same. 

lenticular  nucleus  of  each  hemisphere  and  the  adjacent  caudate  nu- 
clens  and  thalamus.  Such  fibres  would  constitute  those  of  the  internal 
capsule  of  the  cerebrum.  The  capsular  fibres  arise  from  the  cerebral 
convolutions  above  the  plane  of  the  section  and  become  gathered  and 
compressed  into  a  bundle  which  presents  the  peculiar  outline  shown  in 
the  figure.  After  they  escape  from  the  cerebrum  they  are  continued 
downward  into  the  cms  cerebri  of  the  corresponding  side  (Fig.  11). 
They  cease  to  be  capsular  libres  (properly  speaking)  when  the3'  leave  the 
limits  of  the  basal  yanulia  of  the  cerebrum. 


CEREBRAL   HEMORRHAGE.  269 

It  will  be  observed  that  the  right  internal  capsule  is  divided  in  the 
diagram  into  distinct  regions.  The  region  (a)  contains  fibres  whose  dis- 
tribution and  functions  are  not  as  yet  thoroughly  understood,  although 
they  are  probably  indirectly  connected  with  the  cerebellum  ;  the  region 
(/)  probably  contains  fibres  going  to  the  face  exclusively;  the  region 
{m)  ai)pears  to  contain  fibres  of  motion  to  the  opposite  extremities  and 
lateral  half  of  the  body  ;  the  region  (.s)  contains  sensory  fibres  to  the 
same ;  the  region  (.s  t)  contains  the  fibres  of  the  motor  speech-tract 
(Wernicke),  shown  also  in  Fig.  24.  Finally,  the  region  (o)  contains  fibres 
that  are  apparently  designed  to  join  the  optic  nerves  with  the  convolu- 
tions of  the  occipital  lobes,  and  possibly  some  other  fibres  whose  function 
is  not  yet  ascertained. 

Now,  it  must  be  apparent  to  all  that  an}'  hemorrhage  into  the  sub- 
stance of  the  caudate  nucleus,  the  lenticular  nucleus,  or  the  optic  thala- 
mus of  either  hemisphere,  or  the  development  of  an}'  morbid  condition 
that  would  tend  to  enlarge  them,  would  create  pressure  upon  the  adjacent 
internal  capsule  and  afiect  its  component  fibres.  The  seat  of  the  lesion 
will  greatl}'  modify  the  results  of  such  pressure.  If  the  anterior  part  of 
the  capsule  posterior  to  its  "knee"  be  pressed  upon,  motor  effects  will 
follow  ;  if  the  part  still  farther  back  be  involved,  the  general  sensory  tract 
and  the  optic  fibres  maybe  affected.  Both  sensory  and  motor  effects 
may  be  simultaneously  produced  by  lesions  of  the  thalamus  or  lenticular 
nucleus. 

Lesions  confined  to  the  internal  capsule  do  not  diff'er  materially  in 
their  effects  upon  motion  and  sensation  from  lesions  of  the  masses  of  gray 
matter  that  lie  adjacent  to  it.  In  either  case,  the  compression  of  fibres 
or  their  actual  destruction  will  result  in  the  separation  of  the  limbs  and 
trunk  from  connection  with  large  areas  of  the  cortex.  A  lesion  of  mode- 
rate size  in  the  region  of  the  internal  capsule  would  produce  as  profound 
effects  upon  motion  or  sensation  as  would  one  of  extreme  size  if  confined 
to  the  cortex. 

If  an  apoplectic  clot  within  the  substance  of  the  brain  does  not  pro- 
duce death  by  direct  injury  or  the  filling  of  the  ventricles,  the  patient  gen- 
erally recovers  consciousness  at  the  end  of  several  hours.  The  mental 
faculties,  however,  are  more  slowly  regained.  The  memory  is  confused  and 
the  movements  of  the  tongue  imperfect  for  some  hours  after  the  patient 
seems  to  be  conscious.  We  have  reason  to  anticipate  death,  if  profound 
coma  exists  and  is  extremely  prolonged  ;  if  the  pupils  remain  immoble  ; 
if  the  sphincters  are  relaxed  ;  if  the  pulse  is  slow  ;  and  if  the  respirations 
are  markedly  diminished  in  frequency.  The  reflexes  may  be  abolished. 
The  respiratory  and  circulatory  centres  are  liable  to  be  paralj'zed  if  the 
hemorrhage  involves  the  ventricles  or  the  medulla  oblongata. 

In  favorable  {;ases,  the  paralysis  of  motion  developed  at  the  time  of 


270  LECTURES   ON   NERVOUS   DISEASES. 

1  he  attack  gradually  improves  ;  but  it  seldom  disappears  entirely.  The 
ui)per  limb  is  more  persistently  affected  than  the  lower.  Nothna<iel  ex- 
])lains  the  fact  that  the  lower  limb  is  the  first  to  improve  after  a  hemi- 
l)legic  attack  on  the  ground  that  the  movements  of  the  healthy  side  tend 
to  call  into  play  "  associated  moA'ements"  of  the  unhealthy  member, 
which  are  more  easily  excited  in  the  Icg;  than  in  the  arm.  He  sui)ports 
this  view  by  the  clinical  observation  that  those  movements  in  which  both 
legs  are  employed  (ms  in  walking-  for  example)  are  performed  by  the  en- 
feebled limb  for  some  time  before  individual  movements  of  it  are  pos- 
sible. He  also  l^rings  forward  many  illustrations  of  associated  movements 
in  cases  where  paralysis  of  the  face  and  upper  limb  has  existed.  The 
extensors  of  the  fingers  and  wrist  are  usually  the  last  to  improA'e.  In 
exceptional  cases,  the  lower  linil)  is  the  last  to  show  improvement.  After 
a  lapse  of  time,  post-paralytic  contracture  of  the  flexor  muscles  of  the 
arm  and  fingers  is  generally  observed.     The  characteristic  gait  of  the 


^C^"^ 


I 

Fig.  83. — One  of  the  Attitudes  of  a  Hand  Caused  by  Post-Hemiplegic  Contracture. 

(From  a  photograph.) 

hemiplegic  subject  is  hardl}'  to  be  mistaken  for  any  other  condition.  (See 
page  162.) 

The  face  may  be  turgid  during  the  apoplectic  attack,  or  pale.  The 
former  condition  is  most  common.  As  tlie  coma  deepens,  asphyxia  is 
manifested  Ijy  a  dusky  and  livid  coimtenance.  It  is  stated  by  some  authors 
that  a  pale  face,  if  persistent  during  the  attack,  indicates  a  gradual  hem- 
orrhage. 

Paralysis  of  the  facial  nerve  alone  has  been  observed  by  Dnplay, 
Gruveilhier,  Chevostek,  and  Dupuytren  (quoted  by  Xothnagel)  as  a 
result  of  cerebral  hemorrliage  within  tlie  thalamus  and  corpus  striatum. 

The  marked  relaxation  of  all  the  limbs  which  is  commonly  observed 
in  connection  with  apoplectic  attacks  of  a  severe  type  is  to  be  attributed 
chiefly  to  an  antemia  of  the  parts  adjacent  to  the  clot.  This  antemia  has 
been  produced  by  the  pressure  consequent  upon  the  extravasation.  The 
compensatory  changes  which  take  place  in  the  capillary  vessels  soon 
overcome  the  anaemia;  hence  the  muscular  relaxation  disappears  rapidly 
in  those  members  whose  nervous  commtmication  witli  the  cerebral  hemi- 


CEEEBEAL    HEMOEKHAGE.  271 

spheres  has  not  heeii  severed  hy  the  actual  destruction  done  to  fibres  by 
the  escaping  blood.  Should  cerebral  o-dema  be  an  additional  factor  in 
its  causation  (as  it  often  is),  the  muscular  tone  will  be  more  slowly 
regained. 

The  fact  has  been  mentioned  that  some  of  the  fibres  of  the  internal 
capsule  terminate,  anteriorly,  in  the  motor  convolutions  of  the  cerebral 
cortex.  Although  there  are  still  some  neurologists  of  note  (chiefly  Goltz 
and  his  followers)  who  deny  the  value  of  the  late  attempts  of  Fritsch, 
Hitzig,  Broca,  Ferrier,  Charcot,  Ilughlings-Jackson,  Pitres,  Landouzj', 
Exner,  Chouppe,  and  a  host  of  others,  to  locate  special  centres  within 
the  convolutions  of  the  cortex,  clinical  and  pathological  observations  are 
constantly  being  brought  forward  in  support  of  the  more  generally  ac- 
cepted views.  The  region  which  embraces  these  motor  centres  ajipears, 
however,  to  be  somewhat  limited.  A  critical  review  of  the  recorded 
cases  shows,  I  think,  beyond  cavil,  that  the  white  centre  of  each  hemis- 
phere of  the  cerebrum,  as  well  as  the  cortex,  may  in  some  instances  be 
extensively  diseased  or  injured  without  an}-  motor  or  sensory  results 
which  can  be  determined.  Pathological  evidence  seems  to  demonstrate, 
however,  that  the  region  so  impaired  must  not  be  situated  -where  Jibres 
of  the  infernal  capsule,  which  lie  posteriorly  to  its  knee  (Fig.  82),  sutler 
destruction  or  pressure  if  w^e  expect  to  meet  with  negative  results. 
Abscesses  of  immense  size  have  been  found  in  the  anterior  part  of  the 
frontal  lobe,  as  well  as  in  certain  portions  of  the  temporo-sphenoidal 
lobes  of  the  cerebrum  without  any  sensoiy  or  motor  paralysis  during 
life  to  indicate  the  existence  of  such  a  lesion.  Tumors,  softenings,  and 
the  most  severe  types  of  traumatism  have  likewise  occurred  without 
creating  serious  effects.  Certain  tests  have  been  referred  to  on  page  183, 
which  may  aid  materially  in  the  diagnosis  of  lesions  of  the  white  sub- 
stance of  the  cerebral  hemispheres. 

In  the  case  of  the  parietal,  occipital  and  temporo-sphenoidal  lobes, 
to  which  some  of  tlie  posterior  fibres  of  the  internal  capsule  are  dis- 
tributed, sensory  and  psychical  symptoms  in  addition  to  disturbances 
of  nerves  of  special  sense  ha\e  been  observed  to  follow  circumscribed 
lesions.  A  careful  consideration  of  such  cases  demonstrates  the  functions 
of  these  convolutions  more  or  less  clearly.  Some  arguments  have  been 
advanced  of  late  to  prove  a  relationship  between  the  occipital  lobes  and 
tlie  mental  faculties  in  opi)osition  to  the  more  commonly  accepted  and 
probably  correct  doctrine  that  the  frontal  lobes  are  alone  connected  with 
the  hiohest  intelligence.  The  temporal  lobes  seem  to  exert  an  influence 
npon  the  special  senses  of  smell  and  hearing.  An  apparent  connection 
of  the  optic  and  auditory  functions  with  the  cerebellum  and  optic  thala- 
mus exists.  The  bearing  of  morbid  phenomena  of  the  special  sense  of 
sight  upon  diagnosis  has  been  considered  in  previous  pages. 


272  LECTURES   ON    NERVOUS   DISEASES. 

Let  ine  suggest,  that  it  is  by  no  means  certain  tiiat  lesions,  which 
primarily  effect  the  constricted  portion  of  the  internal  capsule,  may  not, 
in  themselves,  create  sufficient  pressure  upon  tlie  corpus  striatum  and 
the  optic  thalamus  to  cause  interference  with  the  free  action  of  some  of 
the  special  centres  which  are  said  by  Luys  to  exist  within  those  bodies. 
If  this  be  the  case,  many  of  the  interesting  plienomena  due  to  lesions  of 
the  optic  tlialamus,  would  coexist  with  those  symptoms  of  disease  witliin 
the  internal  capsule  already  mentioned.  Ritti's  views  respecting  the  re- 
lations of  the  optic  thalamus  to  hallucinations,  and  those  of  Luys  per- 
taining to  its  olfactor}',  optic,  and  acoustic  functions  have  a  special 
interest  in  this  connection. 

Sensory  Paralysis. — Li  most  cases  of  intra-cerebral  hemorrhage, 
sensation  is  impaired  to  a  greater  or  less  extent  ui^on  tlie  opposite  lateral 
half  of  the  body.  Both  electro-cutaneous  and  electro-muscular  sensibility 
may  be  diminished.  The  anaesthesia  may  even  affect  the  smaller  joints. 
Fig,  81  will  aid  the  reader  in  localizing  lesions  which  Involve  the  sensory 
tracts. 

The  restoration  of  sensibility  after  an  attack  of  apoplexy,  while 
often  not  complete,  is  usually  more  rapid  than  that  of  the  power  of 
motion.  Sul)jective  sensations  may  remain,  however,  such  as  formication, 
hyperaisthesia,  the  feeling  of  cloth  upon  tiie  skin,  etc.  1  have  met  with 
exceptions  to  this  rule,  in  which  the  anaesthesia  remained  complete  after 
the  motor  paralysis  had  nearly  disappeared.  I  believe  that  in  these 
cases,  the  lesion  affected  the  sensory  fibres  of  the  internal  capsule  more 
severely  than  the  motor. 

The  abolition  of  sensation  is  not  always  of  the  same  kind.  In  rare 
instances,  sensations  of  touch  are  not  impaired,  while  tliose  of  tempera- 
ture and  pain  are.  The  appreciation  of  temperature  and  pain  may  also 
be  separately  destroyed. 

Disorders  of  Intelligence  and  Coma. — These  may  both  precede  and 
follow  a  cerebral  hemorrhage.  The  more  common  of  these  effects  are 
evidenced  in  the  memory  and  emotional  faculties.  Some  patients  cry 
more  or  less  persistently^  after  an  apoplectic  stroke.  Occasional^  uncon- 
trollable fits  of  laughter  are  induced.  Insanity  is  comparatively  infre- 
quent. 

The  memory  is  often  seriously  affected,  and  the  patient  relapses  into 
childish  methods  of  thought  or  into  a  state  of  apathy.  From  personal 
observation,  I  am  inclined  to  think  that  the  amount  of  destruction  done 
to  the  brain  influences  these  sequela?,  rather  than  the  seat  of  the  lesion. 
They  are  more  marked  in  cases  where  the  symptoms  of  the  attack  have 
been  severe  than  when  mild. 

The  abolition  of  consciousness  that  accompanies  some  attacks  and 
not  others,  is  to  be  attributed,  in  my  opinion,  to  the  displacement  of 


CEREBRAL   HEMORRHAGE.  273 

cerebro-spinal  fluid  from  the  ventricles,  as  expluined  by  Duret.  This 
symptom  is  certainly  less  frequent  in  cortical  lesions,  that  seldom  atfect 
the  ventricles,  than  in  inti-a-cerebral  lesions,  which  do  so  to  a  marked 
degree. 

Impairment  of  the  Special  Senses. — Respectincj  the  possibility 
of  existence  of  special  centres  of  smell,  sight,  hearing  and  sensation 
within  the  substance  of  the  thalamus  there  are  ditferences  of  opinion 
among  authors  of  note.  Some  clinical  facts  point  strongly  to  a  relation- 
ship between  nerve-flbres  connected  with  certain  special-sense  percep- 
tions and  the  internal  capsule.  It  is  impossible,  with  our  present 
knowledge,  to  definitely  place  the  situation  of  all  the  cortical  centres 
which  preside  over  the  various  special  senses,  or  the  course  of  sep- 
arate fibres  which  seem  to  be  associated  with  them;  but  we  are  forced 
to  admit  that  some  of  the  fibres  of  the  posterior  part  of  the  internal 
capsule  have  a  direct  or  an  indirect  association  with  smell,  sight,  hearing, 
tactile  sensation,  and  taste. 

One  peculiar  lact  cannot  be  omitted,  however,  viz.,  that  hemianopsia 
sometimes  occurs  in  connection  with  lesions  of  the  internal  capsule,  with 
a  difficulty  in  discrimination  of  color. 

When  the  radiating  fibres  of  the  internal  capsule  are  involved  in  a 
lesion  which  creates  a  gradually  increasing  pressure  (as  in  the  case  of 
tumors  which  grow  slowly)  the  fundus  of  the  eye  exhibits  morbid  changes 
in  the  region  of  entrance  of  the  optic  nerve  which  are  of  value  in 
diagnosis.  The  condition  so  produced  is  commonl}-  known  as  the 
''choked  disk.''     (See  Fig.  87.) 

In  exceptional  cases  of  destruction  of  the  internal  capsule,  the  sense 
of  smell  has  been  found  to  be  abolished  on  the  side  opposite  to  the  seat 
of  the  lesion.  This  fact  requires  special  consideration,  as  it  has  been 
shown  that  the  centre  proper  for  olfactory  perceptions  seems  to  be  in 
the  hemisphere  of  the  same  side.  Meynert  claims,  however,  to  have 
demonstrated  the  existence  of  an  olfactory  chiasm  in  the  region  of  the 
anterior  commissure  (in  animals  where  the  bulbs  are  largely  developed) ; 
and  fibres  have  been  traced  in  the  region  of  the  "  subiculum  cornu 
ammonis,"  or  the  tip  of  the  temporo-sphenoidal  lobe,  which  connect  the 
olfactory  centres  with  each  other.  Some  experiments  of  Ferrier  tend  to 
disprove  the  decussation  of  the  olfactory  paths  in  the  anterior  commis- 
sure; so  that  the  question  still  remains  unsettled.  The  sense  of  smell  is 
more  commonly  affected  in  the  nostril  of  the  side  which  corresponds 
to  the  seat  of  the  lesion.* 

Among  the  fibres  of  the  internal  capsule  which  are  distributed  to 
the  temporo-sphenoidal  lobe  some  appear  to  have  some  association  with 

*  Ferrier  reports  a  case  where  smell  and  taste  were  simultaneously  abolished  by  a 
blow  upon  the  top  of  the  head.     Ogle  records  a  similar  instance. 

IS 


274  LECTURES   ON   NERVOUS   DISEASES. 

the  sense  of  hcariiKj :  Imt  c'X|)(.TiiiH'ii1:il  ion  iipou  uiiiuinls  to  (U'ttTmine 
the  exact  sent  of  tlie  centres  of  lieariiiii  tiiul  the  etfects  of  their  destruc- 
tion  are  exceedin<>ly  ditlicult,  because  tlie  evidences  (jf  inipairnient  of 
this  sense  are  more  or  less  vague.  Ferrier  thiidvs,  however,  that  the 
superior  temporal  ron volution  is  \in(|uestional)ly  connected  with  aconstic 
perceptions.  The  area  which  he  maps  out  as  aconstic  in  function  is  quite 
extensive,  and  tlic  late  researches  of  Starr  i-especting  the  effects  of 
cortical  lesions  in  man  upon  the  sense  of  hearing-  tend  to  onlii-m  this 
deduction. 

The  cortex  of  the  pnrifldl  lobe  seems  to  be  chiefly  connected  "with 
tactile  sensibiliti/,  because  its  destruction  has  been  found  to  create  a 
total  loss  of  that  sense  on  the  opposite  side  of  the  body.  (^NlunU,  Tripier, 
Moeli,  and  others.) 

As  regards  taste,  the  results  of  experimentation  upon  the  monkey 
tribe  seem  to  point  to  the  lower  po7-tion  of  the  middle  temporal  convolu- 
tion as  the  probable  seat  of  the  centres  which  are  related  to  that  sense.* 
When  this  region  is  subjected  to  irritation,  certain  reflex-  movements  of 
the  lips,  cheek,  and  tongue  are  observed,  which  seem  to  point  to  an 
excitation  of  the  gustatory  sense.  Its  destruction  causes  abolition  of 
taste. 

Tremor. — A  symi)tom  whieli  ])oints  strongly  to  an  existing  lesion 
of  the  internal  capsule  is  choreiform  movements  following  hemiplegia  or 
hemiana'sthesia.  These  movements  vary  in  type  and  degree.  In  some 
cases,  the  movements  exhibit  the  peculiarities  of  athetosis,  the  Angers  or 
toes  being  thrown  into  active  motions  which  cannot  be  controlled  by  the 
patient;  in  others,  true  ataxia  may  be  developed;  again,  the  spasmodic 
movements  partake  of  the  character  of  genuine  chorea  ;  linally,  a  tremor, 
more  or  less  marked  may  be  detected. 

It  is  not  uncommon  to  find  that  both  hemiplegia  and  hemiaujvsthesia 
may  coexist  with  these  post-paralytic  forms  of  spasmodic  disease;  but 
one  nsually  overshadows  the  other,  the  hemiplegia  being,  as  a  rule,  the 
more  marked.  How  we  are  to  explain  these  hite  phenomena  is  not 
definitely  settled.  They  are  probably  to  be  classed  with  other  morbid 
manifestations  which  paralyzed  muscles  sometimes  exhibit,  chiefly  that 
of  "  late  rigidity  "'  so  often  seen,  concerning  the  canse  of  which  many 
conjectures  have  been  advanced,  but  nothing  of  a  ]iositive  nature 
demonstrated. 

Effects  upon  Temperature. — It  has  been  observed  that  lesions  of 
the  internal  capsule,  if  very  extensive,  are  often  followed  by  a  very 
marked  rise  in  the  temperature  of  the  body.     We  ha^e  yet  much  to  learn 

*This  may  help  to  i-xplain  the  fact  that  injuries  received  upim  the  vertex  and 
occipital  protul)erance  cause,  in  some  instances,  an  abolition  of  taste.  The  temporal  lobe 
being  injured  by  concussion  against  the  adjacent  bone. 


CEREBKAL   HEMOEKHAGE.  275 

coneeniiug  the  vaso-niotor  centreK  which  nre  variously  disposed  within 
the  substance  of  the  brain  and  spinal  cord. 

Abnormal  Posture  of  Head  and  Eyes. — We  have  now  considerc'd 
some  of  the  more  prominent  symptoms  which  are  produced  by  lesions  of 
the  internal  capsule,  and  I  pass  to  one  which  I  believe  to  be  of  great 
value  in  aiding  the  recognition  during  life  of  an  extensive  and  rapidly 
developing  lesion  of  the  wdiite  centre  of  the  cerebral  hemisphere,  viz., 
conjugate  deviation  of  tlie  eyes  and  head. 

Wlien,  in  connection  with  rapid  softening  or  an  extravasation  of 
blood  into  the  substance  of  the  cerebrum  above  the  level  of  the  basal 
ganglia,  this  peculiar  symptom  is  developed  (eitlier  simultaneously  with 
or  following  paralysis  and  coma),  the  patient's  head  and  eyes  will  be 
observed  to  be  turned  covstanth/  (lurt;/  from  the  paralyzed  side  and 
toward  tlie  side  which  is  the  seat  of  the  lesion.  Various  attempts  have 
been  made  by  late  authors  to  throw  discredit  upon  the  clinical  signifi- 
cance of  this  symptom  as  particularly  indicative  of  a  lesion  of  the 
cerebral  hemisphere,  but  I  am  convinced  that  it  is  a  valuable  ditierential 
sign.  Ferrier  has  deuKmstrated  that  a  cortical  centre,  which  he  locates 
in  the  first  and  second  frontal  gyri  near  to  their  bases,  presides  over 
conjugate  movements  of  the  head  and  eyes,  and  causes  dilatation  of  the 
pupils.  He  attribiites  this  symptom,  w^hen  occurring  in  connection  with 
hemiplegia  of  cortical  or  ganglionic  origin,  to  the  unantagonized  action 
of  the  corresponding  centre  of  the  uninjured  hemisphere,  thus  explaining 
the  fact  that  the  distortion  is  toward  the  side  of  the  lesion.  Clinical 
evidence  of  the  correctness  of  this  view  has  been  brought  forward  by 
Hughlings-Jackson,  Priestly  Smith,  Chouppe,  Landouzy,  Carroll,  and 
others;  and,  in  some  cases  re])orted,  the  situation  of  the  lesion  has  been 
verified  by  pathological  observation.  The  opportunity  to  record  i)athO" 
logical  observations  upon  cases  where  this  symptom  was  well  marked 
during  life  is,  unfortunately  for  science,  a  comparatively  rare  one.  It  is 
impossible,  therefore,  to  si)eak  positively  concerning  the  diagnostic  value 
of  this  symptom,  although  the  weight  of  clinical  evidence  seems  to  be 
strongly  in  its  favor. 

Special  Symptoms  of  Cerebral  Lesions. — In  connection  with  cere- 
bral hemorrhage  and  other  lesions  that  disturb  the  functions  of  the  brain 
mechanically,  special  types  of  paralysis  and  other  evidences  of  impair- 
ment of  special  functions  are  liable  to  be  encountered.  A  few  general 
statements  are  all  that  space  will  allow  of  in  reference  to  them.  Figs. 
77,  78,  and  79  will  aid  the  reader  in  appreciating  the  clinical  significance 
of  many  symptoms  caused  by  focal  brain-lesions. 

Of  the  ocular  muscles,  the  internal  rectus  of  one  side  may  alone  be 
paretic.  Dilatation  of  the  pupil,  ptosis,  and  external  squint  coexist  when 
the  motor  oculi  nerve  is  paralyzed.     If  these  symptoms  accompany  a  hemi- 


276  LECTUKES   ON   NERVOUS   DISEASES. 

plegia  of  the  opposite  side,  tlie  lesion  is  witliin  the  fiubsfaiice  of  the  cruii 
cerebyn,  and  on  the  side  corresponding  to  the  eye  syini)toius.  In  such 
instances,  it  is  not  uncommon  to  observe  a  paretic  condition  of  tlie  lower 
part  of  the  face.     (See  Fig.  77.) 

If  the  facial  muscles  are  paralyzed  upon  one  side  and  hemiplegia 
coexists,  the  seat  of  the  lesion  is  within  tlie  substance  of  the  jjons  Varolii. 
If  in  the  ui)per  part  of  the  pons,  the  facial  and  body  palsy  will  lie  upon 
the  same  side.  If  in  the  lower  part  of  the  pons,  the  facial  and  body  par- 
alysis will  be  on  opposite  sides.  In  rare  cases,  a  paresis  of  individual 
facial  muscles  has  been  observed  to  follow  a  cerebral  clot.     (See  Fig.  77.) 

The  sense  of  smell  is  liable  to  be  lost  in  one  nostril  when  the  caudate 
nucleus,  optic  thalamus,  or  the  internal  capsule  of  the  corresponding 
cerebral  hemisphere  is  the  seat  of  the  lesion. 

A  peculiar  form  of  blindness,  known  as  hemianopsia,  has  been 
described  in  the  first  section  of  this  volume.  It  may  assume  several 
types.  The  clinical  deductions  to  be  drawn  from  this  SA'mptom  have 
been  already  given. 

Ataxic  manifestations,  occurring  in  connection  with  evidences  of 
impairment  of  the  sense  of  sight,  open  a  wide  field  for  speculation.  The 
proximity  and  intimate  structural  relations  of  the  cerebellum  with  the 
optic  lobes,  basal  ganglia,  crus,  and  medulla,  suggest  the  possibility  of 
cerebellar  lesions  when  these  two  S3'mptoms  are  present  to  a  marked 
degree. 

The  clinical  value  of  aphasia,  as  a  diagnostic  sj'mptom,  has  been 
discussed  in  preceding  pages.     (See  index.) 

In  the  closing  pages  of  the  first  section  a  general  summarv  of  the 
guides  to  the  localization  of  cerebral  lesions  has  been  given.  Man}- 
additional  points  have  been  given  there  in  detail. 

The  so-called  "  contracture  of  muscles,"'  which  occurs  in  connection 
with  hemorrhagic  foci  and  local  diseases  of  the  brain,  deserve  a  passing 
notice.  Rigidity  of  muscles  may  be  divided,  clinically,  into  those  which 
accompanj'  the  onset  of  the  exciting  lesion,  those  which  develop  soon 
after  the  onset,  and  those  which  appear  late  as  post-paralytic  manifesta- 
tions (usually  from  two  to  five  months  after  the  attack). 

The  first  form  is  most  commonly  observed  in  connection  with  cor- 
tical lesions.  It  disappears  within  a  few  days.  It  is  due  to  mechanical 
irritation  of  the  cortical  centres. 

The  second  form  is  to  be  attributed,  according  to  the  researches  of 
Todd,  to  the  irritation  produced  by  a'  reactive  inflammation  in  the 
neighborhood  of  the  cerebral  lesion. 

The  third  form  possesses  greater  clinical  interest  than  the  others, 
because  of  its  persistency  and  the  deformities  which  it  is  liable  to 
produce.     It  never  affects  all  of  the  paral3'zed  muscles  with  equal  inten- 


CEREBEAL   HEMORRHAGE.  277 

sity.  The  upper  limbs  ure  more  often  uttacked  than  the  legs  ;  the  latter 
l)eing  affected  in  conjunction  with  the  arm,  forearm  or  hand,  if  at  all. 
The  trunk  muscles  escape.  Those  of  the  face  and  neck  are  atfected  infre- 
quently. The  upper  limb  is  usually  flexed  at  the  elbow.  The  hand  is 
jn'onated  and  flexed,  with  the  finuers  drawn  toward  the  palm,  in  a  large 
proportion  of  subjects,  although  the  opposite  condition  may  be  encoun- 
tered in  exceptional  cases.  The  arm  is  generally  drawn  close  to  the  side 
or  upon  the  anterior  aspect  of  the  chest.  The  knee  is  usually  flexed 
when  the  lower  limb  is  aftected.  The  foot  may  be  either  flexed  or 
extended. 

The  intensity"  of  post-paralytic  contracture  varies.  The  joints  tend 
to  become  immovably  lixed,  after  it  has  existed  for  years  without  treat- 
ment. After  prolonged  quietude,  as  in  the  morning  on  awakening  from 
slumber,  the  contractured  muscles  often  become  relaxed ;  but  they  soon 
return  to  their  state  of  rigidity  when  movements  are  attenii)ted. 

Vaso-motor  avd  Trophic  Distiirbmices. — Apoplectic  clots,  in  common 
with  other  forms  of  cerebral  disease,  ma}'  be  productive  of  more  or  less 
disturbance  of  the  vaso-motor  nerves,  which  result  in  modifications  in 
the  temperature,  color,  and  nutrition  of  the  paralj-zed  limbs  and  the 
trunk. 

Not  infrequently  the  paralj'zed  i)arts  are  redder  than  the  health}' 
side,  and  exhibit  an  elevation  of  teniperature.  The  skin  may  become 
(jedematous,  and  the  limb  may  ai)pear  swollen  from  the  infiltration  of  the 
subcutaneous  tissues.  Sweating  of  the  paralyzed  limbs  is  observed  in 
some  instances;  while  in  others  the  reverse  condition  may  ensue,  causing 
the  limb  to  be  dr}-  and  scaly. 

Bed-sores  are  developed  in  some  subjects  soon  after  the  apoplectic 
stroke.  The  nates,  knee,  and  heel  are  the  most  common  seat  of  these 
sores.  They  are  to  be  regarded  as  due  to  some  impairment  of  the 
so-called  "trophic  nerve-tibres." 

The  nails  sometimes  undergo  post-paralj'tic  changes.  Thej'  tend  to 
become  of  a  yellowish  color,  and  are  often  disfigured  with  ridges.  They 
are  more  brittle  than  in  health. 

Occasionally  the  hair  upon  the  paralyzed  parts  grows  long,  thick, 
and  dark. 

The  7 oirjfs  may  become  inflamed  after  paralj'sis.  The  larger  joints 
of  the  paralyzed  side  sometimes  begin  to  exhibit  the  symptoms  of  acute 
synovitis  after  the  lapse  of  a  few  weeks  in  cases  of  cerebral  hemorrhage. 
The  smaller  joints  are  rarely  attacked.  Disorganization  of  the  shoulder- 
joint  has  been  recorded  by  Nothnagel,  Hitsig,  and  others.  It  may  result 
in  dislocation  of  the  humerus. 

Finally,  cerebral  paralysis  is  less  frequently  followed  by  atrophy  of 
the  paralyzed  parts  than  if  due  to  spinal  or  peripheral  causes.     This  is 


27S  LECTiaiES    ON    NEllVOrS   DISEASES. 

i\\\v  piirtly  to  the  Ikct  that  :i  liypcrti-opliy  of  the  skin  is  i):irtieularly 
lial)U'  to  be  developed.  It  may  exist  to  so  i^reat  a  degree  as  to  give  the 
paraUzed  limbs  an  aii])earanee  of  increased  size. 

Differential  Diagnosis. — In  liosi)ital  cases,  wliere  often  the  clinical 
history  of  the  snbject  cannot  be  ol)tuined,  it  is  not  always  easy  to  make 
a  positive  diagnosis  of  cerebral  hemorrhage.  In  the  first  place,  the  Coex- 
istence of  coma  and  paralysis  may  be  dependent  upon  many  other  causes, 
such  as  cerebral  embolism,  cerebral  tumors,  cerebral  softening,  and  com- 
pression of  the  brain  from  depressed  bone,  pus,  and  exudations  of  various 
kinds,  as  well  as  upon  an  apoplectic  clot.  Again,  coma, if  unaccompanied 
with  paralysis  of  motion,  may  possibly  be  an  indication  of  the  poisonous 
effects  of  alcohol,  opium,  unvmia,  and  many  other  substances,  as  well  as 
some  functional  nervous  derangements.  In  the  third  place,  patients  of 
this  kind  frequently  have  wounds  upon  the  head,  as  a  result  of  falling. 
This  may  sometimes  mislead  the  physician  in  attributing  the  coma  to  a 
cerebi'al  cause. 

From  cerebral  emholiam  the  diagnosis  of  apoplexy  is  to  be  made  by 
the  tendency  of  the  coma  to  deepen  in  bad  cases  rather  than  to  improve 
witiiin  twenty-four  houi-s ;  l)y  the  profoundness  of  the  paralj^sis;  by  the 
irregularity  of  the  pupils;  the  slow  pulse;  the  slow,  stertoi'ous,  and 
putting  respiration,  and  other  evidences  of  cerebral  compression;  and 
usually  by  the  absence  of  aphasia.  The  history  of  the  patient  will 
also  assist  in  the  diagnosis,  because  em])olism  has  no  prodromal  sym{> 
toms.  Furthermore,  embolism  occurs  at  any  age;  it  is  frequently  de- 
pendent upon  some  valvular  lesion  of  the  heart;  and  it  occurs  when  no 
evidences  of  arterial  degeneration  are  i)resent. 

From  cerebral  tumors  apoplexy  is  to  be  distinguished  by  the  fact 
that  the  headache  which  may  have  preceded  an  attack  of  cerebral  hemor- 
rhage is  of  a  less  severe  type  and  not  as  well  defined  as  in  tumor;  by  the 
absence  of  the  ''choked  disk"  on  an  ophthalmoscopic  examination;  by 
the  fact  that  some  of  the  cranial  nerves  are  liable  to  be  separately 
affected,  in  case  of  tumor,  before  the  body  is  paralyzed;  by  the 
absence  of  spasmodic  conditions  and  neuralgias,  so  often  encountered 
during  the  development  of  tumor;  by  the  fact  that  syphilis  is  a  common 
cause  of  cerebral  growths;  finally,  should  bilateral  or  alternating  paralysis 
develop,  the  diagnosis  of  tumor  is  strongly  suggested. 

From  uraemic  coma^  apoplexy  is  distinguished  by  the  existing  paral- 
ysis (either  of  motion  or  sensation),  the  absence  of  albumen  and  casts  in 
the  urine,  the  irregularity  of  the  pupils,  the  Hushed  face,  and  the  absence 
of  oedema  or  general  anasarca.  It  should  be  remembered  that  convul- 
sions and  profound  coma  may  exist  in  both  of  these  conditions,  and  the 
prodromal  symjjtoms  may  not  be  markedly  dissimilar. 

In  alcoholic  coma  the  pui)ils  will   be  regular,  the  limbs  will  not  be 


CEKEBRAL    HEMORKHAGE.  279 

purnlyzed,  the  eonui  will  not  be  iis  protouiid  ns  in  apoplexy,  the  breath 
will  smell  of  liquor,  and  alcohol  may  be  deteetetl  in  the  nrine. 

The  coma  of  opium  and  chloral  is  not  attended  with  i)aralysis,  and 
the  ])U])ils  are  markedly  eontracted.  The  l)reathini>:  :uid  pulse  resemble 
those  of  cerebral  compression  in  some  I'espects. 

Compression  of  the  brain  from  in Jlammaforj/  or  seroun  criidation 
could  hardly  be  mistaken  for  apoplexy.  The  history  of  the  case 
Avould  not  point  to  cerebral  hc'niorrliai.e,  nor  would  the  attack  be 
instantaneous. 

The  ditferential  diagnosis  between  ai)oi)lectic  clots  in  the  ditierent 
parts  of  the  brain  have  already  been  considered  at  some  length.  Further 
hints  will  be  given  in  the  closing  pages  of  the  section  upon  the  diseases 
of  the  lu'ain,  which  deal  with  the  localization  of  cerebral  lesions. 

Prognosis. — Whether  it  is  possible  for  a  patient  to  recover  perfectly 
from  an  attack  of  cerebral  hemorrhage  is  a  subject  of  great  importance 
to  every  patient  and  his  friends.  The  question,  if  asked,  can  be  intelli- 
gently answered  as  follows:  (1)  tiie  changes  which  have  occurred  in  the 
brain  are  of  necessity  permanent  to  some  extent;  (2)  the  clot  will  do 
more  permanent  injury  in  some  parts  of  the  brain  than  in  others;  (3)  the 
scar,  which  tends  to  form  in  the  most  favorable  cases,  is  liable  to  cause, 
by  its  presence  alone,  more  or  less  disturi)ance  of  the  cerebral  functions; 
(4)  in  most  cases,  a  tendency  to  a  recurrence  of  the  hemorrhage  exists  ; 
(.5)  sometimes  many  years  elapse  before  a  recurrence  takes  place;  (6) 
tinally,  the  term  "recovery"  must  always  be  taken  in  its  restricted  sense 
when  api)lied  to  apoplectic  subjects. 

The  prognosis  is  the  most  grave  when  the  coma  is  prolonged  beyond 
the  usual  limits,  when  the  temperature  rises  to  an  extreme  point  after  the 
attack  ;  when  the  vagvis  nerve  shows  the  etiect  of  impairment ;  when  the 
symptoms  of  pulmonary  oedema  are  developed;  when  the  sphincters  are 
paralyzed;  when  prolonged  or  frequent  convulsions  accompany  or  folhjw 
the  attack,  and  when  the  pupils  are  widely  dilated. 

In  aged  subjects,  the  prognosis  is  more  grave  than  in  those  of  middle 
life. 

Treatment. — At  the  onset,  in  cases  of  moderate  severity,  the  head 
should  be  kept  elevated  and  cold  compresses  may  lie  applied  to  arrest 
the  escajje  of  blood.  The  stomach  may  be  evacuated  by  running  the 
forefinger  into  the  pharynx  of  the  patient,  or  by  a  stomach-pump  if  the 
attack  should  follow  a  hearty  meal.  The  room  should  be  kept  at  a  com- 
lortably  cool  temperature  (about  60°).  No  food  should  be  given  to  the 
patient  for  twelve  hours  after  the  attack.  Cool  acidulated  drinks  will 
do  no  harm  and  are  often  grateful.  If  the  bowels  I)e  constipated,  they 
should  be  moved  by  a  ])urgative  enema  or  some  mild  saline  cathartic. 
Whenever  the  urine  is  not  passed,  catheterism  should  be  resorted  to.    It 


280  LECTURES   ON    NERYOI^S   DISEASES. 

is  best,  as  a  rule,  to  do  as  little  as  possible  outside  of  these  simple 
measures  until  all  signs  of  cerel»ral  irritation  have  disappeared. 

In  severe  eases  it  is  the  custom  of  some  i)ractitioners  to  administer 
croton  oil  at  once  and  to  l)leed  the  patient.  I  would  caution  the  reader 
in  reference  to  both  i)ractices,  although  they  are  sustained  hy  some 
authors.  Bleeding  is  never  performed  by  me,  and  cathartics  of  an  active 
character  should  never  be  given,  in  my  opinion,  unless  the  bowels  have 
been  obstinately'  constipated  for  several  days  in  succession.  Ice-bags  to 
the  head  and  nape  of  the  neck  tend  to  arrest  the  hemorrhage,  and  are 
a(hisable  at  the  time  of  the  attack.  No  attempts  at  medication,  in  order 
to  promote  absorption,  should  be  made  until  all  signs  of  cerebral  irrita- 
tion have  snl)sided.  To  dose  these  patients  with  enormous  amounts  of 
the  iodide  of  potassium  early  is  to  ni}'  mind  nonsensical,  and  decidedly 
opposed  to  all  known  pathological  facts.  The  aim  of  the  treatinent 
should  be  to  preserve  physical  and  mental  quietude  by  ever}-  known 
means,  and  to  avoid  everything  that  will  tend  to  disturb  it. 

If  any  of  the  symptoms  of  inflammation  appear,  after  the  S3'mptoms 
of  onset  have  subsided  to  a  greater  or  less  extent,  counter-irritation  by 
the  use  of  blisters  or  the  actual  cautery  to  the  back  of  the  neck  and  the 
renewal  of  the  ice-bags  will  be  of  service.  If  the  pulse  becomes  rapid, 
small  doses  of  aconite  may  be  indicated.  Opium  in  small  doses  will 
often  prove  of  aid  in  quieting  restlessness  and  mental  excitement. 

In  about  a  week,  provided  the  case  is  to  go  on  toward  recovery,  the 
patient  will  show  some  desire  to  move  his  paralyzed  limbs,  and  a  slight 
improvement  in  motion  may  be  detected.  By  the  end  of  the  second 
week  the  actual  treatment  of  the  paral3'sis  should  generally  be  com- 
menced. I  question  the  propriety  of  ever  beginning  electrical  treatment 
before  ten  to  fourteen  days  have  elapsed,  even  in  the  most  favorable  cases. 
I  would  also  make  the  same  remark  in  reference  to  massage,  and  the  in- 
ternal administration  of  phosphorus  and  strychnia.  I  believe  that  notli- 
ing  is  lost,  and  much  often  gained,  by  delaying  active  treatment  beyond 
the  time  when  anxious  friends  are  apt  to  clamor  for  it. 

Xutritious  food  should  be  administered  to  the  patient  as  soon  after 
the  attack  as  the  stomach  is  well  able  to  bear  it.  I  have  a  decided 
preference  for  milk  over  any  preparation  of  beef.  I  think  that  an  egg 
broken  into  a  goblet  of  milk  and  made  palataT)le  with  sugar  or  nutmeg 
contains  more  nutrition  in  a  condensed  and  acceptable  form,  which  can 
be  easily  digested,  than  any  other  known  combination.  Still,  Liebig's 
and  Valentine's  extracts  of  beef  are  reliable  and  valuable  preparations, 
and  answer  well  as  a  means  of  administering  nourishment. 

Respecting  the  actual  treatment  of  the  paralytic  symptoms,  massage 
and  electricity  are  the  mechanical  agents  upon  which  to  rely,  and  phos- 
phorus and   strychnia  the  drugs  that  seem  to  be  the  most  beneticial. 


CEKEBRAL   HEMORRHAGE.  281 

Charcot  has  latel}'  advocated  the  use  of  i)owt'rtul  magnets  applied  against 
the  skin  of  the  paralyzed  parts,  and  lias  accomplished  some  apparently 
startling  results.  They  are  too  expensive  and  uncertain  as  3'et  in  their 
results,  however,  to  be  recommended  for  general  use,  even  if  their 
curative  properties  are  to  be  regarded  as  well  established. 

Massage  should  form  an  important  part  of  the  treatment  of  motor 
and  sensory  paralj^sis.  It  not  only  hastens  the  recovery  of  motion  after 
apoplectic  attacks,  but  it  helps  also  to  prevent  the  extreme  post-paralytic 
contractures  that  frequently  follow.  It  should  be  emploj^ed  for  ten  or 
fifteen  minutes  oncre  or  twice  every  day  by  a  person  experienced  in  the 
art.  Massage  does  not  consist  of  rubbing,  j^er  se.  It  is  an  art  in  itself, 
and  should  be  scientifically  performed  when  employed. 

The  faradaic  current  will  answer  well  in  the  treatment  of  apoplectic 
paralj'sis,  provided  that  degenerative  changes  in  the  muscles  do  not 
develop.  The  strength  of  the  current  should  be  sufficient  to  cause  slight 
muscular  contractions,  but  not  so  intense  as  to  create  severe  pain  or 
fatigue.  If  the  muscles  show  secondary  degenerative  changes  the  static 
or  galvanic  current  is  advisable.  It  should  be  emploj-ed  until  the  faradaic 
current  begins  to  show  its  normal  reactions.  A  rapid  improvement  will 
usually  follow  the  use  of  electricit}',  even  in  very  bad  cases. 

The  wire  brush,  as  the  active  pole,  is  the  best  method  of  applj'ing 
the  faradaic  current  for  the  relief  of  sensory  paral3"sis,  in  case  it  exists. 
The  anaesthesia  often  disappears  spontaneousl}',  however;  the  prox:imal 
parts  of  the  limbs  usually  being  the  first  to  exhibit  improvement. 

The  question  of  the  advisability  of  venesection  in  apoplexy-  must, 
to  my  mind,  be  decided  in  the  negative.  The  abstraction  of  blood  from 
the  general  system,  after  a  clot  has  formed  in  the  brain-substance,  or 
upon  its  surface,  cannot  affect  the  existing  lesion,  and  must  necessarily 
tend  to  weaken  the  power  of  reaction. 

Strj'chnia  often  aids  in  effecting  a  cure.  It  may  be  given  b}-  the 
mouth  or  hypodermically.  The  dose  b}'  the  former  method  is  about  one- 
twenty-foiirth  of  a  grain  three  times  a  day,  and  by  the  latter  about 
one-thirtieth  of  a  grain  once  a  day.  This  drug  acts  particularly  well  in 
old  cases  of  cerebral  hemiplegia. 

Phosphorus  is  another  drug  which  may  be  indicated.  It  may  be 
administered  separatelj^  or  in  combination.  Phosphide  of  zinc  is  a 
favorite  salt  with  some  authorities.  The  combination  of  nux  vomica, 
mentioned  in  connection  with  the  treatment  of  cei'ebral  congestion,  acts 
well  in  manj'  cases. 

Post-pa ral^'tic  contractures  are  benefited  greatly  by  massage,  when 
it  is  employed  persistently^  from  the  date  of  their  first  appearance. 

Regarding  mental  treatment,  I  advise  my  patients  to  avoid,  for  man}' 
months  after  an  apoplectic  attack,  all  forms  of  occupation  that  demand 


282  LECTUKES   ON    XEKVOUS    DISEASES. 

prolonged  iiuMilnl  clt'ort,  or  which  occasion  over-excitement  or  fatigue.  I 
instruct  them  |):irticularly  to  dismiss  anxiet}',  as  an  important  step  in  the 
cure,  'rravel,  ahstinence  from  tobacco  or  alcohol,  and  judicions  exercise 
in  the  open  air  are  often  important  aids  in  re-establishing  the  health. 
An  excessive  use  of  the  eyes,  as  in  reading,  is  to  be  prohibited.  The 
digestive  ai)paratus  should  be  carefully  watched,  and  tonics  may  be  given 
with  lienefit  in  many  cases.  I  prefer  quinine  to  all  otlier  tonics  after  the 
case  has  progressed  well  toward  a  cure. 

HEMOEEHACrE   OF   THE    CEEEBRAL   MENINGES. 

In  this  variety  of  hemorrhage,  blood  may  be  found  ( 1 )  ])etween  the 
dura  and  the  skull;  (2)  beneath  tlie  dura;  and  (3)  in  the  snb-arachnoidean 
space.  In  the  previons  section  we  have  discussed  cerebral  hemorrhage 
in  a  general  way  (so  far  as  its  symptomatology  is  concerned);  but  some 
facts  of  value  may  be  given  regarding  this  form  in  contradistinction  to 
apoplexy. 

Morbid  Anatomy. — Clots  between  the  dura  and  the  skull  are  almost 
invariably  due  to  injury.  Hammond  quotes  five  cases  collected  l»y 
Gintrac  which  were  apjiarently  of  idio|)athic  origin,  but  they  are  to  be 
regaixled  as  exceptional. 

The  sub-du)-al  rai-iefi/  is  closely  allied  to  h?ematoma  of  the  menintres 
fpachymeningitis  interna).  It  differs  from  the  internal  form  of  pachy- 
meningitis, however,  in  that  the  hemorrhage  precedes  the  formation  of 
the  investing  membrane  fwliich  is  usually  detected  in  both) ;  and  also  in 
that  the  membrane  does  not  present  a  well-defined  laminated  appearance 
and  a  net-work  of  newly-formed  vessels  between  the  layers.  Further- 
more, the  hemorrliage  is  less  distinctly  circumscribed  than  in  the  cases 
of  hfematoma  observed.  Finally,  this  variety  of  hemorrhage  may  be 
disseminated  over  a  very  extensive  area  of  tlie  brain's  surface. 

In  the  sub-ararhnoidal  vnriefii  the  clot  is  generally  imperfectlv 
organized,  because  of  the  admixture  of  cerebro-s])inal  fluid.  It  is 
frequently  found  at  the  base  of  the  skull.  The  arteries  are  generallv 
atheromatous.  An  investing  membrane  to  the  clot  is  not  i^reseut.  This 
form  of  hemorrha'>e  is  often  associated  with  aneurismal  dilatations  of 
the  large  arteries  forming  the  "circle  of  Willis." 

Etiology. — Infancy  and  old  aue  appear  to  lie  more  frequently  affected 
than  middle  life.  It  is  more  common  during  the  first  and  second  years 
of  life,  and  after  fifty  than  between  those  ages.  The  veins  as  well  as  tlie 
arteries  appear  to  be  liable  to  rupture,  especially  in  young  children,  after 
injury  received  upon  the  head.  Ijater  in  life,  alcoholism,  insolation, 
excesses  in  eating  and  veiierv,  severe  muscular  exertion,  constipation, 
amenorrhoca,  and  atheroma  tend  also  to  excite  it. 

Symptoms. — Mucli  that  has  already  been  said  when  ai)oiilexy  was 


HExMOltKHAGE    OF   THE   CEKEBKAL   MENINGES.  283 

discussed,  respecting  cortical  lesions,  bears  diri'ctly  ui)on  this  ticld. 
Some  clinical  deductions  may  be  drawn,  liowever,  between  lesions  of  the 
extra-dnral  and  sub-arachnoidal  varieties.  The  dura  is  so  ch)si'ly 
attached  to  tlie  base  of  the  skull  that  the  former  variety  may  be 
anntomically  excluded  from  that  region.  Hence  the  effects  of  jiressure 
of  extra-dural  hemorrhages  must,  of  necessity,  be  exerted  chiefly  upon 
the  cerebral  hemispheres.  On  the  other  hand,  sub-arachnoidal  clots 
are  frequent  at  the  base  of  the  skull,  and  may  involve  the  crura  cerebri, 
the  pons,  the  medulla,  the  cerebellar  peduncles,  and  the  cranial  nerve- 
trunks  as  well.  We  would  therefore  l)e  more  liable  to  encounter  disturb- 
ances of  the  special  senses,  or  the  motility  of  the  eyeball,  the  evidences 
of  facial  palsy,  vomiting,  choked  disk,  rotary  movements,  and  extensive 
body-paralysis  in  the  subarachnoidal  variety  than  in  extra-dural  hemor- 
rhage. Coma,  vertigo,  headache,  and  couA-ulsions  may  occur  in  both  of 
these  varieties.  If  the  medulla  is  involved,  reflex  automatic  movements, 
such  as  the  heart's  action,  the  respiratory  rhythm,  the  act  of  swallowing, 
etc.,  are  liable  to  be  more  or  less  disturbed  if  death  does  not  immediately 
occur. 

Small  meningeal  clots  upon  the  convexity  of  the  hemispheres  are 
indicated  often  by  some  special  type  of  monoplegia,  amnesic  or  ataxic 
aphasia,  or  an  impairment  of  some  special  sense.  Extensive  surface 
hemorrhage  of  the  convexity  would  result  in  a  train  of  sj-mptoms  closely 
allied  to  those  of  intra-cerebral  clots.    These  have  already  been  described. 

Differential  Diagnosis. — The  reader  is  referred  to  previous  pages  and 
to  two  tables  which  follow  for  information  respecting  the  diagnosis  of 
apoplexy  and  surface  hemorrhage. 

Prognosis. — -Extensive  surface  hemorrhage  generally  produces  death 
within  a  longer  or  shorter  period,  varying  from  a  few  hours  to  a  few 
weeks.  I  have  known  a  child  to  live  many  days  with  a  clot  that  covered 
nearly  an  entire  hemisphere.  On  the  other  hand,  I  lately  saw  in  consul- 
tation a  gentleman  of  sixty  years  of  age  who  died  of  surface  hemorrhage 
in  a  few  hours  after  coma  set  in.  In  some  instances,  recovery  takes 
place  by  the  clot  becoming  encysted  and  undergoing  al>sorption. 

Clots  at  the  base  of  the  brain  are  liable  to  cause  instantaneous  death 
by  the  pressure  exerted  upon  vital  centres.  The  development  of  vomit- 
ing, or  of  the  so-called  "■  Cheyne-Stokes  respiration "  is  a  symptom  of 
evil  import,  whenever  encountered  in  connection  with  a  cerebral  lesion. 

Treatment. — Nothing  can  be  said  here  in  addition  to  the  suggestions 
oftered  in  the  preceding  section. 

In  closing  the  discussion  of  cerebral  hemorrhage.  I  take  the  liberty 
of  quoting  (with  slight  modifications)  from  the  tliird  edition  of  my  work 
on  •'  Surgical  Diagnosis"  the  following  ditlerential  tables,  which  relate 
more  or  less  directly  to  this  condition  : — 


284  LECTURES    ON    NEKVOUS   DISEASES. 

PARALYSIS   FROiM    CORTICAL  PARALYSIS   FROM   NON-CORTICAL 

CEREBRAL   LESIONS.  CEREBRAL    LESIONS. 

Consciousness. 

Is  seldom  completely  lost  at  the  onset  of  A  sudden   loss  of  consciousness  usually 

jiaralysis,  unless  the  lesion  be  extensive  or  accompanies  the  development  of  the  lesion 

<]ue  to  traumatism.  or  its  manifestation  in  the  form  of  paralysis. 

If  ushered  in  with  an  epileptic  attack,  Convulsions  are  not  usually  [iresent  dur- 

consciousness  is  of  course  lost.  ing  the  "jiaralytic  attack." 

Pain. 

Local  pain  within  the  head  is  often  com-  The  ])atient  is  usually  unconscious  at  the 

plained  of  at  the  time  of  the  attack.  time  of  the  attack  and  for  some  time  after; 

and  (even  after  the  attack)  jiain  in  the  head 
is  a  less  constant  symptom. 

Percussion. 

Percussion  over   the  seat   of  the   lesion  Negative  in  its  results. 

often  elicits  pain. 

Paralysis. 

Monoplegia  (in  any  of  its  forms)  is  ty[ii-  Hemiplegia  or  hemiancesthesia,   more  or 

cal  of  this  condition,  whenever  it  exists.  less  profound,  follow  the  development  of 

Special  groups  of  muscles  are  paralyzed,  the  lesion,  as  a  rule.     Both  may  coexist  in 

and  some  more  than  others.  some  cases. 

The  paralysis  is  often  transitory,  if  the  It  is  slow  in  recovery, 
lesion  be  slight  or  superficial. 

The  group  of  muscles,  which  is  the  last  The  improvement  is  comparatively  vmi- 

to  show  improvement,  may  be  a  valuable  form,  so  far  as  special  groups  of  muscles  are 

guide  in  localizing  the  seat  of  injury.  concerned. 

Sensibility  is  usually  unimpaired.  More  or  less  anesthesia  usually  coexists 

with  the  motor  jiaralysis. 

Muscular  Rigidity. 

The    paralyzed    muscles    often    exhibit  Early  rigidity  of  the  paralyzed  muscles 

rigidity  at  an  ea?7y  date.  is  rare  in  central  cerebral  disease. 

Choreiform  Movements. 

Infrequent  as  a  sequel  to  the  paralysis.  Frequently  follow  the  development  of  the 

hemiplegia  or  hemiansesthesia. 

Electro-Contractility. 

The   paralyzed   muscles   exhibit    normal  May  be  impaired  or  modified,  some  time 

electro-contractility.  after  the  onset  of  [laralysis. 

Sgmptoins  in  Common. 
Both  are  associated  with  motor  paralj'sis. 
"     may  be  associated  with  post-paralytic  rigidity  of  muscles. 
"  "  "  "     sudden  advent. 

"  "  "  "     traumatism. 

"  "  "  "     convulsions. 


HEMORRHAGE   OF   THE   CEREBRAL   MENINGES.  285 


IRRITATIVE   LESIONS   OF   THE  DESTRUCTIVE   LESIONS   OF   THE 

CEREBRAL  CORTEX.  CEREBRAL   CORTEX. 

(Jacksonian  Epilepsy.) 

History. 
Syphilis  is  by  far  the  most  frequent  cause  Syphilis  is  only  one  of  many  causes  of 

of  this  condition.  this  condition,  and  by  no  means  the  most 

common. 

Convulsions. 

The   patient   is   seized   with    convulsive  Convulsions  are  usually  absent. 

attacks   of    the   epileptic   type,  which   are 
followed  by  transient  paralysis. 

The  part  which  ^Vsi  shows  rigidity  during 
the  convulsion  points  toward  the  motor 
centre  for  that  part  as  the  seat  of  greatest 
irritation.  It  may  thus  assist  in  localizing 
the  seat  of  the  lesion. 

Paralysis. 

The  paralysis  is  somewhat  of  the  " mono-  A  well-marked   "monoplegia"   is  devel- 

pleijic'  type,  but  is  usually  transitory.     It      oped,  which  is  more  or  less  permanent  ac- 
is  not  so  well  defined  as  in  the  case  of  de-       cording  to  the  character  of  the  lesion.  Itgene- 
structive  lesions.    It  exists,  as  a  rule,  on  the      rally  affects  the  side  opposite  to  the  lesion, 
side  opposite  to  the  lesion.  The  groups  of  muscles  affected  with  pa- 

ralysis will  aid  in  deciding  as  to  the  seat 
and  extent  of  the  lesion. 

Prognosis. 
Good — on  accountof  its  frequent  syphilitic  Depends  entirely  upon  the  character  of 

origin.  the  lesion,  its  seat,  and  extent. 

CEREBRAL   HEMIPLEGIA.  SPINAL  HEMIPLEGIA. 

Form  of  Attack. 
Onset  usually  sudden.  Onset  may  be  gradual. 

Consciousness  is  often  lost  when  the  lesion  Consciousness  is  not  lost. 

is  centrally  situated  in  the  hemispheres. 

History. 
That  of  some  cerebral  disease,  f^nch  as  apo-  That  of  some  spinal  lesion  situated  in  the 

plexy,  embolism,  softening,  tumor,  etc.  cervical   region,   and   involving   only   one 

lateral  half  of  the  spinal  cord. 

Pupils. 
Are  liable  to  be  irregular.  Are    unaffected,   unless    the   cilio-spinal 

centre  within  the  cervical  region  of  the 
cord  be  involved.  If  so,  the  "  Robertson 
pupil "  may  exist. 

Ophthalmoscopic  Examination. 
May  reveal  the  "choked  disk."  Negative. 


286  LECTURES   ON   NERVOUS   DISEASES. 

Cranial  Neeves. 

The   cranial   nerves    are   frequently   in-  The  cranial  nerves  are  not  involved,  un- 

volved,  causing  paralytic  symptoms — com-       less  a  sclerosis  of  the  cord  extends  upward 
monly  in   the   nostril,  eye,   or   face.     The       late  in  the  disease, 
spinal  senses  are  often  modified. 

Crossed  paralysis  (in  any  of  its   forms)  Crossed  paralysis  is  never  present. 

may  be  present. 

Reflex  Phenomena. 

Are  usually  normal.  Some  of  the  various  reflexes  are  liable  to 

be  impaired  or  lost. 

Spasmodic  Phenomena. 
The  paralyzed  muscles  are  not  rendered  Spasms  of  the  limbs  are  very  frequent, 

particularly  susceptible  to  spasm. 

Electro-Musculae  Phenomena. 
Usually  normal.  Modified   according  to   the   parts  of  the 

cord  which  are  affected  by  the  lesion. 

Sensory  Phenomena. 
Anesthesia  or  Analgesia,  whenever  they  Ansesthesia  or  Analgesia,  when  present 

exist,  are  on   the   same  side  as  the  motor      are  on  the  side  opposite  to  the  motor  paral- 
paralysis.  ysis. 

Sensations  of  burning,  pricking,  formica- 
tion, coldness,  and  heaviness  often  exist  at 
the  onset.  Hypersesthesia  follows.  Subse- 
quently anaesthesia  may  be  developed. 

Respiration. 
Respiration  is  seldom  affected.  Difficulty  in   breathing  is  often  experi- 

enced when  the  spinal  lesion  is  above  the 
origin  of  the  phrenic  nerve. 

Sphincters. 
The  sphincters  are  not  involved,  as  a  rule.  The  vesical  and  anal  sphincters  are  often 

affected  with  inertia  or  paralysis. 

Sexual  Functions. 
The  sexual  power  is  commonly  retained.  The     sexual     power      is     occasionally 

abolished. 

Symptoms  in  Commoii. 
Both  are  associated  with  hemiplegia. 
Both  may  be  associated  with  abnormal  senson,'  phenomena. 


pachymeningitis;  or,  inflammation  of  the  dura  mater. 

This  condition  is  usually  circumscriberl,  and  rarely  sprends  over  tlie 
whole  convexity  of  the  brain.  It  is  of  tAvo  forms,  the  suppurative  and 
the  non-suppurntive.  Because  it  is  frequently  associated  with  extravasa- 
tion of  blood,  it  is  described  by  some  authors  under  tlie  name  of  "hteraa- 


PACHYMENINGITIS  ;    OE,    INFLAMMATION   OF  DURA  MATER.     287 

toma  of  the  dura  mater."  Other  authors  classify  it,  as  regards  the  sur- 
face of  the  dura  involved,  into  the  external  and  the  internal, — the  latter 
being  sanguineous,  if  of  the  chronic  type. 

The  cause  of  this  variety  of  inflammation  often  governs  its  seat,  ex- 
tent, and  variety  ;  hence  its  symptoms  will  be  modified  somewhat  by  its 
method  of  origin. 

Meningeal  hemorrhage  is  classed  by  some  authors  under  the  head  of 
pachymeningitis.  To  my  mind  this  is  illogical  and  opposed  to  pathologi- 
cal data.  Hemorrhage  may  be  one  of  its  causes,  as  well  as  one  of  its 
results,  but  not  one  of  its  varieties,  because  pachymeningitis  is  accom- 
panied by  changes  in  the  dura. 

Morbid  Anatomy. — Suppuration  more  commonly  accompanies  the 
hemorrhagic  variety  and  that  produced  by  caries  of  the  bones.  It  may 
occur  also  after  traumatism,  especially  if  thrombosis  follows.  A  general 
arachnitis  is  then  liable  to  be  induced  as  a  complication  of  the  circum- 
scribed inflammation  of  the  dura.  The  base  of  the  brain  is  usually  ex- 
empt from  this  form  of  meningitis,  except  as  a  sequel  of  traumatism, 
tumors,  or  diseases  of  the  vertebrse.  Hsematoma  is  very  common  at  the 
vertex,  and  sometimes  aflects  both  hemispheres  of  the  brain  simultane- 
ousl}^  by  crossing  the  mesial  line. 

In  the  nonsuppurative  variety  the  dura  becomes  composed  of  super- 
imposed layers  (as  high  as  twenty  in  some  instances).  These  are  rich  in 
vessels  (which  tend  to  rupture  w'here  the  arterial  tension  is  excessive 
from  any  cause).  The  dura  subsequentlj'  becomes  united  to  the  arach- 
noid. The  layers  of  a  hsematoma  occasionally  ossify.  When  the  newly- 
formed*  vessels  sometimes  rupture,  they  tend  to  create  circumscribed 
sanguineous  cysts.  When  syphilitic  caries  is  the  exciting  cause,  the 
dura  may  become  gangrenous. 

The  external  variety  is  always  a  secondary  inflammation.  The  dura 
is  found  to  be  injected,  softened,  and  ecchymotic  in  its  initial  stage. 
Later  on,  new  connective-tissue  formations  induce  a  thickening  and 
opacity  of  the  dura,  and  adhesions  take  place  between  it  and  the  skull, 
provided  suppuration  does  not  occur.  Pigmentation  of  the  dura  and  the 
formation  of  osteophytes  in  that  membrane  are  sometimes  encountered. 

Secondary  thromboses  of  the  cerebral  sinuses  m;iy  follow  a  pachy- 
meningitis. These  may  suppurate  and  induce  metastatic  abscesses  of 
the  viscera  (as  explained  on  page  230). 

Etiology. — The  causes  which  tend  to  produce  pachymeningitis  are 
as  follow:  (1)  injuries  to  the  cranial  vault ;  (2)  syphilitic  disease  of  the 
bones  of  the  cranium,  most  commonly  of  the  temporal;  (3)  hemorrhage 
between  the  dura  mater  and  the  bone;  (4)  diseases  of  the  vertebrae  and 
tlieir  ligaments  ;  (5)  thrombosis  of  the  cerebral  sinuses,  chiefly  the  trans- 
vex'se  and  petrosal;    (6)  chronic   inflammation  of  the  middle  ear;    (1) 


288  LECTURES   ON   NERVOUS   DISEASES. 

suppurative  inflammation  of  the  orbit;  (8)  clironic  alcoholismus ;  (9) 
pyaemia;  (10)  Brighit's  disease;  (11)  rheumatism;  and  (12)  acute  infec- 
tious diseases. 

Symptoms. — Lesions  of  this  character  may  excite  paralysis  of  parts 
supplied  by  cranial  nerves  which  lie  adjacent  to  them;  and  wlien  the 
pressure  becomes  extreme,  paralysis  of  the  limbs  and  even  coma  may 
follow. 

Localized  pain  is  usually  present  over  the  seat  of  the  disease;  and 
percussion  of  tiie  skull  over  the  lesion  tends,  as  a  rule,  to  increase  the 
pain. 

The  defective  blood-supply  (in  those  convolutions  of  the  brain 
which  lie  adjacent  to  the  lesion)  that  ensues  from  pressure  upon  them 
may  lead  to  softening.  When  suppuration  occurs,  the  symptoms  are 
greatly  aggravated. 

In  many  cases,  the  symptoms  of  the  external  variety  are  very 
obscure,  especially  at  the  onset.  When  somnolence,  vertigo,  headache 
of  a  localized  type,  delirium,  photophobia,  convulsions,  or  coma  follow 
any  of  the  causes  enumerated  among  the  etiological  factors,  it  may  be 
well  to  suspect  the  existence  of  one  of  the  two  varieties. 

Chronic  inflammation  of  the  middle  ear  is  often  regarded  by  parents 
as  of  trivial  importance,  and  ph3'Sicians  not  infrequently  advise  them  to 
that  effect ;  j^et  it  is  one  of  the  most  prolific  causes  of  this  serious 
condition,  and  is  liable  to  produce  death  if  not  properly  cared  for. 

If  thrombosis  of  some  of  the  cerebral  sinuses  has  existed  and  created 
this  complication,  tiie  prodromal  symptoms  will  be  those  enumerated  in 
connection  with  thrombosis. 

Syphilis  is  a  prolific  cause  of  pachymeningitis,  because  it  often 
induces  a  carious  state  of  the  cranial  bones  and  an  extension  of  the 
inflammation  to  the  adjacent  dura,  which  tends  toward  suppuration. 
Cerebral  symptoms,  when  occurring  in  connection  with  syphilis,  should 
always  be  the  sulyect  of  careful  inquiry. 

The  INTERNAL  VARIETY  of  this  disease  may  occur  idiopathically, — 
chiefly  in  connection  with  chronic  alcoholism,  the  hemorrhagic  diathesis, 
blood-poisoning  from  urea,  scurvy,  pernicious  anaemia,  leucocytluemia, 
general  paresis,  hydrocephalus,  cerebral  atrophy,  cerebral  tumors,  and 
pyaemia.     It  may  also  develop  secondarily  to  the  external  variet}'. 

The  S3'mptoms  of  the  internal  vnriety  are  liable  to  be  more  distinctly 
defined  than  are  those  of  the  external,  because  the  development  of 
a  haematoma  of  the  dura  creates  localized  pressure  upon  the  brain  or 
some  of  the  cranial  nerA'cs,  the  severity  of  which  depends  upon  its  size 
and  seat.  Hence  we  are  liable  to  encounter  evidences  of  impairment  of 
intellect,  temporary  loss  of  consciousness,  aphasic  symptoms,  early  con- 
traction and  subsequent  irregularity   of  the   pupils,  exacerbations  and 


pachymeningitis;  ok,  inflammation  of  dura  mater.    289 

remissions  of  temperature,  slowing  of  the  pulse,  choked  disk,  and  a 
gradual  paralysis  of  motion  or  sensation,  which  may  be  preceded  by 
convulsive  attacks.  Headache  is  a  marked  symptom  as  a  rule,  especially 
in  the  syphilitic  variety.  The  hemorrhages  that  occur  in  this  variety 
are  constantly  recurring  because  the  newly-formed  vessels  are  in  a  loose 
connective-tissue  formation,  and  are  often  atheromatous.  This  fact 
possibly  helps  us  to  explain  win*  these  patients  have  short  periods  of 
loss  of  consciousness,  transient  paralyses,  convulsive  attacks  at  infre- 
quent intervals,  and  periodical,  headache.  Sudden  death  may  follow  an 
extensive  hemorrhagic  extravasation.  Bilateral  paralj'^sis  may  result 
from  hi^matoma  of  the  dura,  when  it  is  situated  at  the  vertex  and  crosses 
the  sagittal  suture. 

The  SYPHILITIC  VARIETY  is  classcd  as  distinct  from  the  others  by 
some  authors,  because  the  deposit  upon  or  beneath  the  dura  is  usually 
of  a  gummatous  nature.  In  this  variety,  localized  headache  is  very 
persistent  and  usually  grows  worse  as  night  approaches.  Special  cranial 
nerves  are  not  infrequently  involved  before  the  cerebral  functions  are 
disturbed  in  any  w^ay.  I  have  made  the  diagnosis  of  this  condition  in 
several  cases  by  the  development  of  hemianopsia;  also  by  the  existence 
of  motor  oculi  paralysis,  and  facial  paralysis  alone.  I  once  saw  a  patient 
who  lay  in  profound  coma  with  dilated  pupils,  stertorous  breathing,  and 
relaxed  sphincters  from  this  cause  for  ten  days  and  eventually  recovered. 
Cases  of  this  type  of  pachymeningitis  may  exhibit  symptoms  of  insanity 
early.  On  the  other  hand,  they  may  become  dull,  stupid,  and  apathetic, 
before  other  symptoms  develop  which  may  assist  in  definitely  localizing 
the  seat  of  the  lesion.  In  exceptional  cases,  I  have  seen  hemiplegia 
develop  from  this  cause  without  an3'  prodromal  symptoms. 

DifFepential  Diagnosis. — The  obscurity  of  the  symptoms  in  all  forms 
of  pachymeningitis  renders  its  differential  diagnosis  rather  a  matter  of 
conjecture  than  of  scientific  accurac}'.  The  following  hints  may  aid, 
however,  in  the  discrimination : — 

1.  In  case  necrosis  of  the  cranial  bones,  otitis  media,  fracture  of 
the  cranium  or  traumatism  of  the  skull  has  existed  and  been  followed  by 
evidences  of  gradual  cerebral  compression,  we  may  strongly  suspect  the 
existence  of  dural  inflammation. 

2.  When  a  htematoma  is  developing,  the  symptoms  may  resemble 
those  of  either  acute  or  chronic  meningitis  or  cerebral  softening,  and  a 
positive  diagnosis  may  be  impossible.  Bilateral  paralysis  is  strongly 
indicative  of  htematoma.  The  following  symptoms  are,  in  my  experi- 
ence, also  strongly  diagnostic  :  Contraction  of  the  pupils ;  localized  head- 
ache; transient  and  recurring  attacks  of  unconsciousness  or  paralysis: 
a  slow  pulse;  strabismus;  ptosis;  and  facial  palsy. 

3.  In  connection  with  syphilis,  the  development  of  cerebral  symi)toms 

19 


290  LECTUEES   ON   NERVOUS   DISEASES. 

of  any  kind  should  excite  a  suspicion  of  the  existence  of  pachymenin- 
gitis of  the  guiiiinatous  variety.  The  cranial  nerves,  especiallj^  the 
olfactory,  optic,  motor  oculi,  and  facial,  are  apt  to  be  involved  and  to  give 
clinical  evidence  of  more  or  less  impairment  of  function. 

The  following  table  is  quoted  from  the  third  edition  of  the  author's 
work  on  "  Surgical  Diagnosis:" — 

EXTERNAL  PACHYMENINGITIS.  INTERNAL  PACHYMENINGITIS. 

(HEMATOMA   OF    THE   DuRA   MATEE.) 

Causes. 

Traumatism  of  the  calvaria.  Chronic  alcoholism  and  syphilis. 

Diseases  of  the  cranial  bones.  Acute  febrile  disorders  (fevers,  rheuma- 

Cariesandnecrosisof  the  cervical  vertebrae.  tism  and  puerperal  diseases). 

Suppurative  diseases  of  the  vertebral  liga-  Chronic  .diseases  of   the  heart,  tubercu- 

ments.  losis,  and  the  paralysis  of  the  insane  may 

It  rarely  follows  syphilitic  or  rheumatic  be  a.?sociated  with  it. 

conditions  of  the  cranium  or  erysipelas  of  Old  age. 

the  scalp.  Males  more  frequently  affected  than  fe- 
males. 

Headache. 

Intense  and  circumscribed  headache  usu-  Periodical    headache   is   commonly   pro- 

ally  exists.  duced ;  gradually  reaching  extreme  intensity 

whenever  the  acute  form  exists. 

Convulsions. 

Slight  convulsions   are   common   at   the  Convnilsions  are  rare, 

onset. 

Brain  Symptoms. 

Vertigo,  nausea,  and  vomiting   are   fre-  Weakness    of  memory,   apathy,   somno- 

quently  met  with  at  the  onset  of  the  disease.       lence,  and  delirium  are  the  more  common 

symptoms. 

Pupils. 

The  pupils  are  apt  to  become  unequal,  if  The  pupils   are  not  necessarilv  affected, 

the  pressure  upon  the  brain  is  severe.  because  the   pressure   of   the    sanguineous 

cyst   is   more  limited   than  that  of  a  pus 
exudation. 

They  may  he  contracted. 

Pulse. 

The  pulse  is  at  first  accelerated,  but  be-  The  pulse  fails  to  exhibit  the  effects  of 

comes  slow  and  irregular  when  cerebral  general  cerebral  compression,  except  in 
compression  is  produced.  severe  and  fatal  cases. 

Late  Symptoms. 

Coma  and   paralysis   follow   if   cerebral  Feebleness  of  the  limbs,  unsteady  gait, 

compression  or  abscess  is  produced.  and  changes  in  the  nutrition  indicate  the 

latent  progress  of  inflammation  of  the  brain. 

Symptoms  in  Common. 

Both  may  be  associated  with  headache. 
"  "  "  "     convulsions. 

"  "  "  "     coma. 

"  "  "  "     paralysis. 

"  "  "  "     syphilitic  history. 


pachymeningitis;  oe,  inflammation  of  dura  matee.    291 

Prognosis. — Patients  may  recover  from  pach^^meningitis,  in  spite  of 
the  fact  tliat  tlie  prognosis  is  usually  grave.  In  alcoholic  patients,  the 
disease  is  generally  fatal.  If  suppuration  is  developed,  the  dangers  to 
life  are  materially  enhanced ;  hence  the  prognosis  is  grave  if  it  be  induced 
by  caries,  necrosis,  otitis  media,  cancer,  traumatism,  etc, 

Haematoma  of  the  dura  is  fatal  in  a  very  large  percentage  of  those 
attacked.  These  patients  maj^  die  from  hemorrhage,  cerebral  thrombosis, 
cerebritis,  dementia,  pyaemia,  and  other  complications,  before  the  tumor 
produces  death  by  direct  pressure  upon  the  brain.  Life  may  terminate 
between  the  limits  of  two  weeks  and  two  years,  according  to  the  circum- 
stances incident  to  the  case. 

In  the  syphilitic  variet}'  of  pachymeningitis  I  have  witnessed  some 
very  remarkable  recoveries.  When  the  gummatous  deposit  is  small,  it 
may  be  absorbed  by  active  specific  treatment.  If  it  be  large,  the  brain 
ma}^  be  softened  and  permanently  impaired  before  the  cause  can  be 
removed,  I  have  often  observed  a  tendenc}'^  toward  a  return  of  the  symp- 
toms in  many  of  these  subjects  that  have  been  greatl}'  benefited  at  first 
by  treatment.  If  chronic  alcoholism  is  a  factor  in  the  causation,  as  well 
as  syphilis,  the  prognosis  is  very  grave;  but  recovery  may  occur  even 
under  these  circumstances.  I  latel^^  saw  a  remarkable  instance  of  that 
character  in  connection  with  my  late  colleague  Prof.  A.  L.  Loomis. 

Treatment. — When  pachymeningitis  is  of  the  suppurative  type, 
surgical  interference  may  overcome  the  difticulty  to  a  large  extent  by 
evacuating  the  pus.  It  is  not  always  possible,  however,  to  localize  the 
situation  of  the  pus  or  even  to  determine  its  presence  with  certaint3\ 
The  cause  may  aid  in  this  discrimination,  in  some  cases.  Traumatic 
causes,  otitis  media,  and  caries  or  necrosis  are  especially  prone  to  purulent 
deposits  between  the  dura  and  the  bone.  A  careful  study  of  the  symp- 
toms (from  the  standpoint  of  cerebral  physiology)  may,  in  exceptional 
cases,  indicate  the  seat  of  the  abscess.  I  have  given  the  surgical  guides 
for  the  emplo3'ment  of  the  trephine  in  such  cases  in  my  work  upon 
nervous  anatomy,*  and  also  in  the  first  section  of  this  volume. 

During  the  development  of  a  haematoma  of  the  dura  life  may  be 
prolonged  by  a  judicious  use  of  ergot,  stimulants,  and  a  nutritious  diet, 
in  conjunction  with  enforced  physical  and  mental  quietude  and  counter- 
irritation.     I  do  not  believe  that  any  line  of  treatment  will  effect  a  cure. 

In  the  gummatous  variety,  I  have  found  tlie  best  results  to  follow 
mercurial  fumigation  and  the  internal  administration  of  large  doses  of 
the  iodide  of  potash  (grs.  xxx.  to  Ix.  after  each  meal,  and  even  larger 
doses  if  necessary).  I  prefer  the  black  oxide  of  mercury  (one  drachm 
to  a  bath)  to  any  other  preparation  when  fumigation  seems  advisable, 

*"The   Applied  Anatomy  of  the  Nervous  System."     D.  Appleton   and  Co.,  N.Y., 
2d.  edition  1888. 


292  LECTURES   ON   NERVOUS   DISEASES. 

although  calomel  baths  act  well  in  some  cases,  if  watched  carefully  to 
avoid  salivation.  I  have  frequently  employed  inunctions  of  one  drachm 
of  the  20  per  cent,  oleate  of  mercury  night  and  morning  with  benefit, 
when  the  baths  were  not  to  be  obtained;  but  the  effects  are  less  certain 
and  the  treatment  more  disagreeable  to  the  patient  than  by  the  bath. 
In  one  case  I  carried  the  iodide  of  potash  up  to  a  dailj^  administration 
of  one  and  a  half  ounces  for  several  consecutive  days  before  I  got 
satisfactory  results.  The  subcutaneous  sublimate  injection,  recom- 
mended by  Lewin,*  has  yielded  excellent  results,  in  some  instances, 
xmder  my  observation.  I  frequently  employ  it  in  connection  with  mer- 
curial fumigation.  In  those  cases  where  the  iodide  of  potash  is  badly 
tolerated,  I  have  employed  the  iodide  of  calcium  with  excellent  results. 
This  salt  is  unstable,  and  should  be  carefully  bottled  by  the  manufac- 
turers so  as  to  prevent  its  decomposition.  It  may  be  given  in  the  same 
doses  as  the  other  salt.  All  of  the  iodides  should  be  administered  in 
combination  with  Vichy  water,  and  very  largely  diluted. 

The  employment  of  cod-liver  oil  and  tonics  is  advisable  in  these 
cases,  as  they  are  anaemic  and  badly  nourished  as  a  rule.  All  stimulants 
should  be  withheld,  unless  serious  damage  to  the  patient  is  indicated  by 
so  doing.  In  such  a  case  they  should  be  decreased  in  amount  steadil}'  as 
fast  as  practicable. 

I  have  personally  discarded  for  some  years  past  the  old  routine 
management  of  cerebral  syphilis  by  the  internal  administration  of  the 
so-called  "mixed  treatment."  It  does  not  accomplish, in  my  experience, 
what  the  fumigation,  inunction,  or  subcutaneous  injection  methods  will; 
nor  is  it,  to  my  mind,  free  from  other  serious  objections.  My  convictions 
upon  this  point  are  strong,  and  are  based  upon  quite  a  large  experience 
in  the  management  of  these  cases.  It  is  not  necessary  for  me  to  defend 
my  views  here;  but  it  cannot  be  denied  that  one  essential  factor  in  suc- 
cess in  these  cases  is  unimpaired  digestion.  Even  if  the  improvement 
was  as  rapid  under  the  old  plan  as  the  new  (which  it  certainly  is  not) 
the  digestive  organs  are  more  freciuently  deranged. 

ARACHNITIS. 

Thickening  and  opacity  of  the  arachnoid  has  been  observed  in  con- 
nection with  atheroma,  cancer  of  the  abdominal  viscera,  granular  kidney, 
senile  dementia,  delirium  tremens,  tuberculosis,  heart-lesions,  cerebro- 
spinal meningitis,  hemorrhage  into  the  pia  mater,  and  as  a  sequel  to 
disease  of  the  bone  and  the  dura  mat(>r. 

It  may  be  associated  with  an  effusion  of  lymph  or  pus,  and  be  either 
local  or  general. 

The  exciting  cause  will  be  of  the  greatest  aid  in  determining  its  char- 
*  "  Syphilis,"  by  Georjje  Lewin.     Blakiston,  Sou  &  Co.,  1882. 


INFLAMMATION   OF   THE   PI  A   MATER,    ETC.  29o 

acter  during  life.  It  is  often  impossible  to  discriminate  during  life  be- 
tween lesions  involving  tlie  dura  mater  from  tliose  of  tlie  araclnioid  ;  and 
it  is  still  more  difficult  to  separate  its  morbid  conditions  from  tliose  of 
the  adjacent  pia  mater  whicli  underlies  it,  and  which  usually  participates 
to  a  greater  or  less  extent  in  its  ciianges. 

Atheromatous  degeneration  of  tlie  cerebral  vessels  seems  to  be  com- 
monl^^  associated  with  those  forms  which  have  their  apparent  origin 
either  in  cancer  or  the  abuse  of  alcohol.  As  is  the  case  with  all  inflam- 
matory conditions  of  the  coverings  of  the  brain,  the  symptoms  are  pro- 
duced either  by  the  hyperemia  in  the  early  stages,  or  by  the  pressure  of 
the  exudation  upon  the  brain,  or  from  cerebral  thrombosis  in  the  later 
stages  of  the  disease. 

INFLAMMATION    OF   THE   PIA   MATEE — DIFFUSED    MENINGITIS   OF 
THE   CONVEXITY   OF   THE   HEMISPHERES. 

We  have  alread}^  discussed  diseased  conditions  of  the  dura  under  the 
heads  of  meningeal  hemorrhage  and  paclijmeningitis,  and  it  now  be- 
hooves us  to  consider  the  pia  mater  in  its  pathological  aspects. 

Meningitis  maj'  be  subdivided  into  four  forms  :  the  acute,  subacute, 
chronic,  and  tubercular.  The  acute,  subacute,  and  chronic  varieties  of 
inflammation  of  the  pia  are  generall^'^  diffused  over  the  convexity  of  tlie 
cerebral  hemispheres.  The  tubercular  variety  (hydrocephalus)  is  com- 
monly conflned  to  the  base  of  the  brain  to  a  greater  or  less  extent. 

The  varieties  of  meningitis  will  be  considered  separately,  because 
their  pathology  and  symptomatology  difl"er  widely. 

ACUTE    MENINGITIS. 

Synonyms. — This  condition  is  described  b}'  authors  of  note  under 
the  following  heads:  1,  Simj)le  meningitis  of  the  convexity ;  S.  General 
arachnitis;  3.  Cerebral  fever ;  4-  Non-specific  injlammalion  of  the  men- 
inges: 5.  Acute  cerebral  leptomeningitis. 

Morbid  Anatomy. — On  removal  of  the  calvaria,  the  surface  of  the 
hemispheres  appears  of  a  greenish  hue.  This  is  due  to  the  presence 
of  an  exudation  into  the  meshes  of  the  pia  and  the  peri-vascular  13'mph 
spaces. 

The  vascularity  of  the  meninges  is  excessive.  The  vessels  appear  to 
the  eye  as  prominent  red  lines  running  over  a  green  background.  The 
base  of  the  brain  is  usually  free  from  abnormal  appeai-ances. 

The  pia  is  thickened,  reddened,  and  rendered  opaque  in  spots.  In 
some  cases  the  arachnoid  and  the  dura  may  be  adherent  to  each  other. 
Alonir  the  main  fissures  and  the  more  important  sulci,  a  creamy  exuda- 
tion (consisting  of  an  admixture  of  serum,  fibrin,  and  pus,  in  varying 
proportions)  is  found.     It  constitutes  in  many  cases  an  approach  to  a 


294  LECTURES   ON  NERVOUS   DISEASES. 

fulse  membrane,  which  can  be  readily  detached  from  the  convolutions 
underneath  it. 

When  tiiis  false  membrane  is  raised,  the  surface  of  the  brain  is  seen 
to  be  dotted  over  with  small  red  spots.  These  indicate  capillary  extrava- 
sations from  the  small  branches  of  the  vessels  of  the  pia,  which  every- 
where supply  the  cortex. 

Occasionally  the  cerebellar  meninges  are  implicated.  Whenever 
this  is  the  case  it  is  common  to  find  the  cranial  nerves  more  or  less 
encapsulated  in  a  sheath  formed  bj'  the  exudation. 

If  the  exudation  upon  the  cerebral  hemispheres  be  large  in  amount, 
the  cerebral  convolutions  will  appear  more  or  less  flattened,  the  sulci  will 
be  deeper  than  normal,  and  the  ventricles  will  contain  little  if  any  fluid. 

Cross-sections  made  through  the  white  substance  of  the  cerebrum 
will  often  reveal  minute  spots  of  extravasation, — the  so-called  "puncta 
vasculosa." 

Etiology. — Among  the  predisjyoaing  causes  of  this  disease  may  be 
mentioned:  (1)  age,  since  youth  or  3'oung  adult  life  is  most  commonly 
attacked;  (2)  sex,  because  males  are  more  often  attacked  than  females; 
(3)  anxiet}',  prolonged  mental  labor,  and  grief;  and  (4)  excessive  indul- 
gence in  alcohol. 

The  exciting  causes  include  (1)  injuries  to  the  bones  of  the  head; 
(2)  caries  or  necrosis  of  the  cranial  bones;  (3)  otitis  media;  (4)  insola- 
tion ;  (5)  extension  of  inflammation  from  the  orbit  and  the  vertebral 
ligaments;  (6)  metastasis  of  skin  eruptions;  (7)  blood-poisons,  chiefly 
those  of  the  fevers,  pyaemia,  rheumatism,  uraemia,  diabetes,  diphtheria, 
and  rheumatism. 

Meningitis  maj^  be  of  idiopathic  origin  in  rare  instances,  according 
to  some  authorities.  I  have  always  doubted  the  accuracy  of  this  state- 
ment, if  the  term  be  used  in  its  true  sense. 

Symptoms. — In  the  early  stages  of  acute  meningitis  the  symptoms 
ma3"  be  regarded  as  those  of  cerebral  irritation  combined  with  marked 
febrile  excitement. 

A  persistent  and  intense  headache  exists  from  the  onset,  accom- 
panied by  contracted  i)upils,  vertigo,  photophobia,  and  profectile  vomit- 
ing in  many  cases.  The  attack  may  begin  with  a  chill.  The  tempera- 
ture may  rise  to  105°  or  106°  in  a  severe  case;  but  it  seldom  exceeds  102° 
or  103°.  The  highest  temperature  usually  occurs  from  the  fifth  to  the 
seventh  day. 

Cutaneous  hi/persesthesia  and  muscular  twitchings  are  developed 
early. 

The  gait  is  tottering  and  indicates  an  impairment  of  coordination  in 
the  early  part  of  the  disease.  A  continuous  high  temperature  is  an  indi- 
cation of  a  fatal  termination. 


ACUTE  MENINGITIS.  295 

The  frequency  of  the  pulse  (which  is  small,  firm,  and  tense)  varies. 
It  ranges  proportionately  with  the  remissions  and  exacerbations  of  the 
tomijerature. 

Finally,  constipation  and  retraction  of  the  abdomen  are  usually 
pi'esent  during  the  stage  of  headache.  With  children,  it  is  not  uncom- 
mon to  have  the  first  stage  ushered  in  with  convulsions  and  marked 
strabismus. 

The  face  is  pale,  as  a  rule,  during  the  initial  stage  of  meningitis,  and 
the  conjunctiva  is  injected.     Occasionally,  the  face  may  be  flushed. 

As  headache  is  the  prominent  symptom  of  this  stage,  its  character 
should  be  fully  described.  It  is  intense  from  the  onset,  and  is  associated 
with  an  excitation  of  the  special  senses.  It  steadily  tends  to  grow  worse, 
instead  of  better^  It  may  be  confined  to  the  frontal,  temporal,  or  occi- 
pital regions  of  the  head.  It  may  last  for  a  variable  space  of  time, — 
from  a  few  hours  to  as  many  days. 

In  most  respects  the  initial  stage  of  acute  meningitis  resembles  that 
of  intense  cerebral  congestion.  Hence  what  has  been  said  respecting  the 
symptoms  of  that  condition  will  apply  here. 

Second  Stage. — Delirium  usually'  sets  in  after  the  stage  of  headache 
has  lasted  for  a  longer  or  shorter  period  (seldom  more  than  a  few  days). 
It  is  accompanied  by  an  increase  of  the  fever,  jactitation,  restlessness, 
and  mental  excitability,  or  confusion  of  intellect.  So  prominent  a 
feature  does  delirium  now  become  that  this  stage  is  denominated  the 
"  stage  of  delirium''''  by  some  authors.  It  sometimes  becomes  so  active 
that  it  resembles  acute  mania.  Hallucinations  of  sight  and  hearing  often 
accompany  the  delirium,  and  the  articulation  of  the  patient  frequently 
becomes  incoherent.  In  the  aged,  the  delirium  is  of  the  tj'phoid  char- 
acter, and  is  manifested  by  incessant  talking,  accompanied  by  irration- 
ality of  ideas.  The  patient  may  laugh  or  weep  over  imaginary  occur- 
rences, and  is  apt  to  gesticulate  wildly.  Twitchings  of  the  facial 
muscles  and  a  peculiar  rolling  of  the  ej-eballs  in  the  orbits  are  commonly 
observed.  Occasionally  the  flexors  of  the  limbs  contract  powerfully  and 
produce  episthotonos.  Convulsions  in  adults  are  rare,  but  they  sometimes 
occur.  Hemiplegia  and  paraplegia  are  infrequent,  although  I  have  per- 
sonally observed  the  former  in  one  instance.  Hammond  reports  two  cases 
where  hemiplegia  persisted  throughout  the  entire  course  of  the  disease. 

When  the  medulla  is  implicated  or  the  nerve  trunks  which  arise  from 
it,  the  acts  of  respiration  and  of  swallowing  may  be  imperfectly  per- 
formed before  coma  develops.  The  pulse  may  then  become  irregular, 
the  abdomen  will  be  retracted,  and  projectile  vomiting  maj^  exist. 

Occasionally  the  delirium  merges  into  attacks  of  insanity,  with 
homicidal  or  suicidal  tendencies.  Hence  it  is  well  to  guard  against  such 
accidents  b}-  keeping  a  close  watch  over  the  patient. 


296  LECTURES   ON  NERVOUS  DISEASES. 

Finally,  an  herpetic  eruption  occurs  not  infrequently  during  this 
stage. 

Third  Stage. — After  several  days  have  elapsed  frf)m  tlie  onset  of  the 
attack,  the  patient,  as  a  rule,  becomes  more  quiet  and  gradually  sinks 
into  the  state  of  profound  coma.  The  headache  of  the  first  stage,  and 
the  cutaneous  hypenesthesia,  as  well  as  the  delirium,  the  jactitation,  and 
the  contractures  of  the  second  stage,  give  place  to  a  stiijxir  that  deepens 
from  hour  to  hour.  The  pupils  begin  to  exhibit  oscillations  and  grad- 
ually become  dilated.  The  pulse  becomes  very  slow,  irregular,  and  inter- 
mitting in  character.  The  patient  grinds  the  teeth,  picks  at  the  bed- 
clothes, and  often  develops  ptosis  and  more  or  loss  facial  paralysis.  The 
urine  is  passed  unconsciously,  and  the  bowels  are  often  niove<l  in  the  bed. 
Sometimes  retention  of  urine  occurs,  and  a  catheter  has  to  be  passed  at 
re2;ular  intervals.  Tiie  temperature  remains  elevated  until  death  is  immi- 
nent, when  it  often  falls  rapidly.  The  jurlse  becomes  very  rapid,  as  death 
approaches,  and  can  with  extreme  difficulty  be  counted  at  the  wrist. 
The  Cheyne-Stokes  respiration  develops,  the  body  becomes  clammy  and 
bathed  in  a  cold  sweat,  and  life  is  extinguished  as  a  result  of  heart-failure, 
asphyxia,  or  pulmonary  oedema. 

In  this  stage  of  coma  and  collapse  the  face  may  become  alternately 
pale  and  sufl'used,  or  it  may  assume  a  purplish  color  from  asphyxia. 
The  head  may  be  drawn  toward  one  side. 

DifFerential  Diagnosis. — This  disease  may  be  confounded  with  de- 
lirium tremens,  typhus  fever,  acute  uraemia,  small-pox,  and  encephalitis. 

From  delirium  tremens,  this  disease  may  be  told  by  the  absence  of 
the  clammy  sweat  during  the  stage  of  delirium,  the  presence  of  headache, 
and  the  peculiar  character  of  the  delirium.  The  temperature,  the  pupils, 
and  the  pulse  are  also  widely  different  from  those  of  alcoholism. 

From  typhus  fever,  meningitis  may  be  diagnosed  by  the  incompressi- 
bility  of  the  pulse,  the  comparatively  low  range  of  teai|)erature,  the  ab- 
sence of  the  mahogan}'  or  leaden  face,  the  hypemesthesia  of  the  surface, 
the  projectile  vomiting,  and  the  absence  of  the  characteristic  eruption  of 
tj'phus. 

From  acute  uraemia,  it  may  be  differentiated  by  a  urinal  analj'sis, 
which  will  fail  to  reveal  the  presence  of  casts  or  blood,  and  by  the  absence 
of  frequent  and  severe  convulsions.  There  will  be  no  oedema  of  the 
eyelids,  and  the  face  is  pale  rather  than  turgid.  Evidences  of  cerel)ral 
compression  will  also  be  present,  and  the  temperature  will  aid  greatly 
in  excluding  urttmia. 

From  small-pox,  meningitis  can  be  told  by  the  absence  of  pain  in  the 
loins  and  back,  the  absence  of  the  characteristic  eruption  on  the  third 
da}'  of  the  disease,  and  the  presence  of  projectile  vomiting.  Until  the 
eruption  occurs  the  diagnosis  is  difficult. 


SENILE  MENINGITIS.  297 

From  circinn^cribed  eyicephalitis^,  the  distinction  is  made  hy  the 
intensity  of  tho  headache,  the  activity  and  peculiar  character  of  the 
delirium,  the  severe  muscular  contractures,  the  active  febrile  symptoms, 
and  the  rapid  development  of  collapse. 

Senile  3IenivgitU. — When  meningitis  of  the  acute  form  occurs  in 
the  aged,  the  sj^mptoms  dirter  mai'kedly  from  those  described  as  typical 
of  that  condition  in  the  infant  or  young  adult.  The  headache  is  either 
absent  or  not  severe.  The  rise  in  temperature  is  not  so  well  marked. 
The  projectile  vomiting  is  usually  absent,  and  gastric  derangement  is  not 
developed,  as  a  rule. 

Senile  meningitis  so  closely  resembles  cerebral  softening  that  some- 
times it  is  with  ditliculty  ditierentiated  from  it.  The  speech  is  often 
incoherent,  the  monory  impaired,  and  man^'  of  the  acts  of  the  patient 
appear  irrational.  Coma  may  occur  in  the  initial  stage.  The  delirium, 
when  it  exists,  is  of  a  low  and  muttering  type.  It  is  common  for  these 
patients  to  develop  paresis  of  all  the  limbs. 

The  diagnosis  of  this  type  of  meningitis  from  cerebral  softening  is 
made  chiefly  by  the  rapidity  of  its  progress  and  the  absence  of  the  pro- 
dromal symptoms  that  usually  precede  softening  of  the  brain. 

Prognosis. — In  any  of  the  varieties  described,  the  prognosis  is 
always  unfavorable.  Severe  cases  usually  terminate  fatally  within  ten 
days;  less  acute  cases  may  end  in  recovery.  We  are  justified  in 
anticipating  a  fatal  termination  when  paralysis  of  the  limbs  occurs, 
when  ptosis  or  strabismus  is  present,  when  hiccough  exists,  when  the 
temperature  is  high  and  shows  no  remissions  in  the  morning,  and 
when  the  Cheyne-Stokes  respiration  is  developed.  The  prognosis  of 
any  form  of  meningitis  is  always  more  favorable  in  childhood  than 
in  adults. 

Treatment. — The  first  and  second  stages  of  this  disease  are  char- 
acterized mainly  by  symptoms  of  cerebral  congestion  ;  hence,  general 
blood-letting  by  leeches  to  the  neck  or  temples  and  b}'  venesection  at 
the  elbow  are  indicated.  Leeches  maj'  be  applied  also  inside  of  the 
nostril  (so  as  to  directly  deplete  the  superior  longitudinal  sinus)  or 
over  the  mastoid  region,  to  deplete  the  lateral  sinus.  I  doubt  the 
advisability  of  ever  employing  extensive  blood-letting  in  children  ;  but, 
in  adults  of  a  vigorous  constitution,  as  high  as  fifteen  ounces  of  blood 
may  be  abstracted  from  the  vessels. 

Tlie  second  agent  to  be  employed  is  cold  to  the  head.  The  hair 
should  be  shorn  and  ice  applied  to  the  scalp  throughout  the  first  and 
second  stages.  The  i-oom  should  be  darkened  and  all  disturbing  influ- 
ences should  be  carefully  gunrilcd  against.  The  rubber  coil,  through 
which  iced  water  is  allowed  to  flow  continuously,  is  an  excellent  and  per- 
haps the  best  way  of  keeping  the  hea<l  under  the  influence  of  cold.     It  is 


208  LECTURES  ON  NERVOUS  DISEASES. 

best  to  maintain  an  elevated  posture  of  tlie  head,  so  as  to  assist  the 
venous  return. 

Active  catharsis  is  a  third  agent  which  can  be  employed  to  advan- 
tage. Croton  oil  is  always  reliable  and  prompt  in  its  action.  Calomel 
is  also  good,  especially  if  its  action  is  accelerated  by  the  addition  of  jalap 
or  podophyllin. 

The  administration  of  small  doses  of  calomel  (one  grain  every  two 
hours)  and  also  the  employment  of  the  iodide  and  bromide  of  potash 
have  been  suggested.  My  experience  with  the  iodide  of  potash  has  been 
very  satisfactory  in  some  cases.  Regarding  the  use  of  the  bromide  of 
potash,  Dr.  Hammond  reports  that  very  great  benefit  has  been  afforded 
in  eases  intrusted  to  his  care  by  the  daily  administration  of  from  ninet}'' 
to  one  hundred  and  twenty  grains  of  that  salt  from  the  onset  until  the 
stage  of  delirium  had  jjassed.  Three  of  his  cases  recovered  under  this 
treatment. 

I  have  not  had  as  good  results  with  the  continued  administration  of 
calomel  as  those  reported  by  Hammond  and  others. 

In  the  stage  of  coma  and  collapse,  blisters  may  be  applied  at  the  nape 
of  the  neck  or  the  actual  cautery  may  be  employed  as  a  counter-irritant. 
All  medication  should  be  abandoned  in  this  stage,  and  the  patient  should 
be  stimulated  and  nourished.  My  guide  to  the  employment  of  stimulants 
is  the  effects  which  they  have  upon  the  pulse  and  temperature.  If  they 
tend  to  bring  both  nearer  to  the  standard  of  health,  I  continue  their 
administration.  I  believe  that  many  patients  die  from  the  lack  of  stimu- 
lants in  a  crisis  of  disease,  especially  in  inflammatory  conditions  of  the 
meninges.  Champagne,  brandy,  and  whiskey,  are  preferable  to  port  and 
sherry.  I  am  in  tiie  habit  of  giving  stimulants  often  in  small  doses  and 
in  combination  with  systematic  feeding  at  short  intervals.  Beef-tea, 
beef-juice,  milk,  pure  cream,  and  a  raw  egg  beaten  in  milk  are  my  favorite 
methods  of  giving  nourishment  in  these  cases.  In  the  aged,  the  use  of 
stimulants  is  indicated  early  in  the  course  of  the  disease. 

Finally,  the  condition  of  the  bladder  and  the  bowels  should  be 
carefully  watched  in  this  stage,  especially  in  the  case  of  extremely  old 
subjects.  Retention  of  urine  in  comatose  patients  is  liable  to  be  over- 
looked by  the  attendants  and  to  cause  great  distress.  A  catheter  should 
be  introduced  into  the  bladder  of  patients  so  afflicted  at  regular  intervals 
during  the  day  and  night. 

SUBACUTE  CEREBRAL  MENINGITIS. 

This  variety  differs  from  the  acute  in  that  it  is  a  secondary  condition 
(being  the  result  of  some  exhausting  disease),  nnd  also  in  that  the 
duration  of  the  attack  is  longer,  tlie  brain-symptoms  less  marked,  and 
the  prognosis  proportionately  less  grave. 


CHRONIC   CEREBRAL  MENINGITIS.  299 

Morbid  Anatomy. — The  pathological  changes  differ  little  from  that 
of  the  acute  form,  except  in  that  the  exudation  contains  a  smaller  pro- 
portion of  pus  and  fibrin,  and  is  less  extensive  in  amount.  The  loss  of 
lustre  and  opacity  of  the  pia  is  less  extensive  and  adhesions  of  the  pia 
to  the  dura  or  to  the  cortical  brain-substance  are  less  common. 

Etiology. — We  are  liable  to  encounter  this  form  of  meningitis  as  a 
complication  of  chronic  Bright's  disease,  cancerous  deposits,  typhoid 
fever,  chronic  diarrhoea,  rheumatism,  and  other  exhausting  diseases. 

Symptoms. — The  development  of  this  complication  is  usually  indi- 
cated  by  delirium.  The  stage  of  headache  and  the  initial  chill  are  not 
present  as  a  rule.  If  headache  exists,  it  is  moderately  severe  and  lasts 
but  a  few  hours.     Jactitation  generally  precedes  the  onset  of  delirium. 

The  delirium  is  not  as  active  as  in  the  acute  form.  The  patient 
develops  a  desire  to  constantly  get  out  of  bed,  but  is  easily  induced  to 
return.     Muttering  and  an  unsteadiness  of  gait  develop. 

The  stage  of  coma  is  liable  to  come  on  rapidly.  The  pulse  becomes 
slow,  the  respirations  sighing  or  puffing  in  character,  and  cyanosis 
rapidly  supervenes.  Convalescence  in  patients  who  pass  into  the  stage 
of  coma  is  very  slow.     Death  is  the  more  common  termination. 

Rheumatic  meningitis  may  occur  through  metastasis,  and  as  a  com- 
plication of  that  disease.  It  may  be  of  the  subacute  or  chronic  variety. 
It  is  often  fatal. 

Differential  Diagnosis. — Many  hints  given  in  connection  with  the 
diagnosis  of  apoplexy  from  the  various  forms  of  coma  encountered  (p.  278) 
will  apply  here,  because  coma  is  the  prominent  symptom  of  this  variety 
of  meningitis.  The  cause  is  an  important  factor  in  the  discrimination 
in  every  case  of  suspected  meningitis.  Some  of  the  differential  diagnoses 
mentioned  when  the  acute  form  was  considered  might  be  repeated  here. 

Prognosis. — When  subacute  meningitis  occurs  as  a  complication  of 
chronic  Bright's  disease  and  rheumatism,  it  is  generally  fatal.  The 
chances  of  recovery  are  better  when  it  develops  from  the  blood-poisoning 
of  fevers,  or  accompanies  exhausting  diseases. 

Treatment. — Blisters  at  the  nape  of  the  neck  are  often  attended 
with  great  benefit.  If  uraemia  exists,  the  elimination  of  the  poison 
should  be  hastened  by  catharsis,  hot-air  baths,  and  diuretics.  If  it  be 
due  to  exhaustion,  stimulants  are  indicated. 

CHRONIC   CEREBRAL   MENINGITIS. 

This  variety  of  meningitis  may  be  confined  to  the  convexity  of  the 
cerebrum  or  to  the  base  of  the  brain.  It  is  essentially  a  disease  of  adult 
life.  It  is  a  common  lesion  in  some  forms  of  insanity.  The  symptoms 
will  be  modified  greatly  by  the  seat  of  the  disease.  If  basilar  in  tyjJe, 
the  cranial  nerves  are  especially  liable  to  become  involved. 


300  LECTURES   ON   NERVOUS   DISEASES. 

Morbid  Anatomy. — Tlie  connective-tissue  elements  of  the  pia  are 
chierty  ali'ected  in  this  form  of  meningitis.  We  encounter,  therefore,  an 
opaque  and  tliickened  condition  of  tliat  membrane,  and  an  abundance  of 
new  connective-tissue  cells.  Tlie  coats  of  the  vessels  of  the  pia  are  often 
thickened.  The  branches  which  nourish  the  cortex  are  sometimes 
enclosed  in  meshes  of  new  connective-tissue  which  bind  the  pia  to  the 
brain's  surface.  It  is  tlierefore  frequently  found  to  be  difficult  to 
remove  that  membrane  without  tearing  away  portions  of  the  brain.  The 
connective-tissue  of  the  brain  (the  neuroglia)  sometimes  participates  in 
the  inflammatory  process.  Hence  ditfuse  interstitial  encephalitis  ma^-  be 
one  of  the  complications  or  sequelaj  of  chronic  inflammation  of  the  pia. 

Chronic  meningitis  is  usually  more  or  less  circumscribed  in  extent. 
When  pachymeningitis  has  been  an  exciting  cause  of  this  condition,  the 
pia  will  be  adherent  to  the  dura  and  appear  thickened  and  very  opaque. 

The  cortex  may  be  found  to  have  undergone  atrophy,  as  a  result  of 
long-continued  pressure  or  impairment  of  its  vascular  supply. 

Finally,  an  ettusion  which  consists  of  serum,  pus,  or  lymph  may  be 
detected  in  the  meshes  of  tlie  pia.  Tubercle  has  occasionally  been 
ol)served  upon  the  convexity  of  the  hemispheres  in  this  form  of  menin- 
gitis. Cysts  may  be  developed  by  an  encapsulation  of  the  serous  deposit 
by  false  membranes.  The  Pacchionian  bodies  along  the  cerebral  falx 
may  be  increased.  The  ventricles  are  liable  to  contain  an  excess  of  fluid 
over  the  normal  amount. 

Etiology. — This  form  of  meningitis  is  commonly  a  secondary  affection. 
It  is  met  with  as  a  complication  of  syphilis,  gout,  rheumatism,  chronic 
kidney -disease,  alcoholism,  prolonged  exposure  of  the  head  to  extreme 
heat,  or  the  rays  of  the  sun,  and  tuberculosis.  It  may  be  developed 
idiopathically,  especially  in  subjects  who  are  badh'  nourished,  or  who 
have  suffered  from  privation,  mental  anxiety,  grief,  or  great  emotional 
excitement.  I  recall  one  case  that  was  apparenth'  induced  by  a  religious 
revival.  Hammond  states  that  cooks  are  Acrv  prone  to  develop  this 
disease,  on  account  of  the  exposure  of  the  head  to  heat.  This  disease 
is  seldom  met  with  until  adult  life.  It  is  more  common  after  the  fiftieth 
year  than  before  it. 

This  form  of  meningitis  Tany  occasionally  follow  the  acute  variety. 
It  may  also  be  induced  by  injuries  received  upon  the  head. 

Symptoms. — I  have  several  times  encountered  the  pathological 
evidences  of  well-marked  chronic  meningitis  at  an  autopsy,  when  its 
existence  had  not  even  been  suspected  during  life.  I  mention  this  fact 
•as  an  illustration  of  the  obscurity  of  the  symptoms  in  some  instances. 

In  many  cases,  the  symptoms  resemble  those  of  general  paresis. 
The  mind  of  the  patient  is  usual!}'  aflected,  so  that  intimate  friends 
observe    a  change  in  the  disposition    or   the   intellectual   attainments, 


CHRONIC   CEREBRAL   MENINGITIS.  301 

nlthough  the  s^-mptoms  of  menta,!  impairment  miglit  escape  a  casual 
observer.  Moroseness,  i)eevisliness,  apathy,  somnolence,  and  delusions 
are  frequently  develoi)ed. 

The  muscular  power  of  the  patient  begins  to  show  impairment  later. 
The  act  of  walking  is  often  rendered  difficult,  on  account  of  a  trembling 
of  the  legs.  The  sphincters  begin  to  act  imperfectly,  so  that  the  jjatient 
is  often  unable  to  prevent  soiling  of  the  clothing.  The  articulation  of 
words  sometimes  becomes  affected.  The  speech  is  occasionally  so  blurred 
and  indistinct  that  only  friends  can  understand  what  the  patient  says. 
Paralysis  of  motion  or  sensation  may  be  developed  in  the  limbs,  in  some 
cases. 

Headache,  which  is  increased  by  any  mental  or  physical  exertion,  is 
one  of  the  most  common  symptoms.  It  is  persistent,  but  not  particularly 
severe.  In  connection  with  chronic  kidnej-disease,  this  s^'mptom  forms 
a  peculiarly  striking  feature.  Epileptic  convulsions  often  follow  the  headi- 
ache,  if  the  meningitis  be  due  to  this  form  of  blood-poisoning. 

Vomiting  of  a  persistent  type  is  a  symptom  that  is  very  frequently 
present  in  many  cases.     It  is  associated  with  great  physical  exhaustion. 

The  cranial  nerves  may  give  evidence  of  this  disease  when  the  base 
of  the  brain  is  implicated.  Facial  palsy,  strabismus,  ptosis,  irregu- 
hirity  of  the  pupils,  sloughing  of  the  ball  of  the  eye,  ischsemia  of  the 
])apilla  of  the  retina,  actual  blindness  or  hemianopsia,  choked  disk,  im- 
pairment of  the  power  of  deglutition,  irregularity  in  breathing,  and  slug- 
gish movements  of  the  tongue,  may  develop  and  be  clinical  guides  to  the 
progress  and  seat  of  the  lesion. 

Finall}-,  vertigo,  buzzing  in  the  ears,  specks  before  the  vision,  attacks 
of  numbness  and  of  hyperesthesia  in  the  limbs,  and  general  convulsions 
may  coexist  with  the  symptoms  already  mentioned. 

Profound  coma  usually  occurs  before  a  fatal  termination.  It  is  the 
result  either  of  pressure  upon  the  cerebral  hemispheres  or  a  mechanical 
anjiemia  of  the  brain. 

Differential  Diagnosis. — This  is  extremely  difficult,  and  often  impos- 
sible. We  have  in  the  majority  of  cases  to  deal  with  a  combination  of  the 
symptoms  of  meningeal  inflammation  and  those  of  cerebral  inflammation, 
combined  with  the  mechanical  ettects  of  pressure  upon  the  nerve  centres. 
It  is  not  always  possible  to  decide  positivel}'  between  such  a  medley  of 
symptoms  and  those  whicli  accompany  cerebral  softening  and  cerebral 
tumors. 

The  history  of  the  patient  may  be  of  the  greatest  importance  in  the 
discrimination. 

From  uncomplicated  cerebral  softening^  chronic  meningitis  is  to  be 
told  by  the  persistency  and  severit}^  of  the  headache;  the  absence  of  the 
history  of  a  previous  apoplectic  attack ;  the  vagueness,  so  to  speak,  of 


302  LECTURES   ON   NERVOUS   DISEASES. 

the  mental  symptoms;  the  infrequency  of  muscular  contractions;  and 
the  presence  of  undue  mental  excitement.  As  chronic  meningitis  and 
cerebral  softening  are  often  associated,  the  diagnosis  may  be  impossible. 

From  cerebral  tumor,  chronic  meningitis  is  to  be  distinguished  by 
the  character  of  the  headache,  which  is  more  intense  and  circumscribed 
where  a  tumor  exists,  by  the  frequent  paralysis  of  the  cranial  nerves  in 
case  of  tumor,  and  hy  the  slow  development  of  mental  symptoms  when 
a  tumor  is  present.  Moreover,  the  ophthalmoscope  will  usually  reveal 
the  charactei'istic  appearances  of  choked  disk  (fig.  87)  when  a  tumor  is 
developing  within  the  cavity  of  the  skull. 

It  must  be  borne  in  mind,  however,  by  the  reader  that  tumors  of  the 
brain  or  its  meninges  are  frequently  associated  with  a  chronic  meningitis 
of  a  circumscribed  character  which  is  excited  by  the  neoplasm.  In  such 
a  case  the  symptoms  of  both  conditions  would  be  so  intermingled  as  to 
render  a  differential  diagnosis  impossible. 

Prognosis. — When  s^-philis  is  the  cause  of  chronic  cerebral  menin- 
gitis, active  treatment  in  the  earl}'  stages  may  eftect  a  rapid  cure.  Hence 
the  prognosis  is  much  more  favorable  in  patients  who  give  a  history'  of 
prcAious  syphilitic  infection  than  in  those  who  do  not. 

The  majority'  of  cases  of  chronic  non-specific  meningitis  do  not 
usuallj'  take  so  favorable  a  course  under  any  form  of  treatment,  although 
recovery  has  been  known  to  occur.  Manj^  of  this  t^-pe  of  patients  de- 
velop insanity  or  some  complicating  diseases  of  the  viscera,  chiefly 
pneumonia  and  pulmonary  oedema.  Others  may  die  from  inanition  or 
the  mechanical  etfects  of  direct  pressure  upon  the  brain  by  the  exudation. 

The  tendency  of  this  disease  is  toward  progression,  as  a  rule.  The 
prognosis  is  therefore  unfavorable,  provided  syphilis  can  be  excluded 
from  the  factors  of  its  causation. 

Treatment. — If  the  disease  be  of  syphilitic  origin,  I  invariably  em- 
ploy subcutaneous  injections  of  the  corrosive  sublimate  of  mercury  or 
the  mercurial  bath.  I  use  these  in  connection  with  the  internal  adminis- 
tration of  large  doses  of  the  iodide  of  potash  or  calcium.  I  am  convinced 
that  the  effects  of  the  iodides  are  more  lasting  (even  in  tertiary 
S3'philis)  when  combined  with  a  mercurial  treatment  than  when  given 
alone.  The  effects  of  the  mercurial  bath  or  of  the  sublimate  injections 
are  more  immediately  beneficial  to  my  mind  than  those  gained  by 
the  administration  of  mercurials  in  an}'  other  way.  In  fact,  I  have 
arrested  sj'mptoms  in  this  way  which  all  other  methods  have  failed  to 
relieve. 

In  non-specific  cases,  I  have  given  the  iodides  in  large  doses,  and 
sometimes  minute  doses  of  the  bichloride  of  mercur}'  by  the  stomach. 
I  also  emplo}'  the  bromides  in  combination  with  ergot. 

When  paral^'sis  is  developed,  it  is  m^'  custom  to  place  the  patient  at 


TUBERCULAE   MENINGITIS — HYDEOCEPHALUS.  303 

once  upon  strychnia  and  electricit3\    Strychnia  niaj^  be  injected  into  the 
paralyzed  muscles  if  the}'  fail  to  improve  rapidly. 

Counter-irritation  at  the  back  of  the  neck,  either  by  the  actual 
canter}',  severe  static  sparks,  or  blisters,  often  does  good.  In  some 
instances  a  seton  may  be  introduced  at  this  point  to  keep  up  active 
counter-irritation. 

The  bowels  and  the  bladder  should  be  the  objects  of  careful  super- 
vision. It  may  be  necessary  in  some  cases  to  nse  a  catheter  at  regular 
intervals,  and  possibly  to  irrigate  the  bladder  when  symptoms  of  cystitis 
appear. 

Finally,  the  mental  S3'mptoms  must  be  treated  by  enforced  quiet  of 
both  the  mind  and  body.  The  milk  diet  (from  two  to  three  quarts  a 
day)  and  the  exclusion  of  all  other  foods  has  given  happy  results  in  my 
hands  in  many  forms  of  mental  disorders.  I  frequently  keep  a  patient 
strictly  upon  this  regimen  for  several  weeks.  Some  of  my  patients  have 
lived  largely  upon  milk  for  many  months. 

The  hot-water  treatment,  to  which  I  have  referred  elsewhere,  is 
indicated  in  some  cases  as  a  valuable  adjunct  to  the  remedies  already 
mentioned. 

TUBEECULAR  MENINGITIS — HYDEOCEPHALUS. 

Meningitis  of  the  tubercular  type  (the  so-called  attacks  of  "  water 
on  the  brain  ")  is  most  commonly  observed  during  childhood. 

The  acute  variety  is  described  by  German  authors  under  the  name 
of  "  basilar  meningifis,^^  because  the  morbid  lesions  are  limited  to  the 
base  of  the  skull.  English  authors  employ  the  term  "  acute  hydroceph- 
alus,'''' when  speaking  of  this  variety. 

The  "  chronic  variety "  of  tubercular  meningitis  differs  radically 
from  the  acute  form  in  its  morbid  anatomy,  symptoms,  and  duration. 

The  two  will  be  discussed  separately  because  of  their  wide  dissimi- 
larity. 

ACUTE  HYDEOCEPHALUS. 

The  pia  mater,  in  this  disease,  becomes  the  seat  of  tubercular  de- 
posits and  intlammatory  exudation  at  the  base  of  the  brain. 

It  is  essentiall}^  a  disease  of  childhood,  although  it  maj'  occasionally 
be  observed  in  the  adult. 

Huguenin  describes  under  the  term  "  leptomeningitis  infantum  "  a 
form  of  hydrocephalus  of  the  acute  variety,  which,  in  his  opinion,  is 
purely  intlammatory,  and  is  not  associated  with  the  formation  of 
tubercle.  He  excludes  all  "  predisposition  "  of  an  hereditary  character 
to  this  disease.  Among  the  exciting  causes  of  this  variety  of  hydroceph- 
alus he  mentions  the  following :  dentition,  eruptive  fevers,  pulmonary 
diseases  which   are   accompanied  with   high   fever,  concussion  of   the 


304  LECTURES   ON   NERVOUS   DISEASES. 

(U'uiiiiim,  intestinal  catarrh,  and  the  ingestion  of  alcohol.  He  considers 
an  acute  clIiisiiMi  into  tlie  ventricles  of  the  brain  as  the  chief  pathological 
manifestation  of  this  variety  of  hydrocephalus. 

Morbid  Anatomy. — I  shall  confine  my  remarks  upon  this  head  to  the 
(!onditions  found  in  typical  case?  of  acute  hydrocephalus  of  the  tubercu- 
lous type.  These  include  (1)  deposits  of  tubercle;  (2)  an  exudation  of 
an  inflammatory  character  in  the  meshes  of  the  pia ;  and  (3)  a  dropsical 
effusion  into  the  ventricles. 

In  the  perivascular  lymph  spaces,  chiefly  but  not  exclusivel}"  at  the 
base  of  the  brain,  we  find  deposits  of  miliary  tubercles.  They  are  most 
abundant  at  the  bifurcations  of  the  blood-vessels.  They  tend  to  mechan- 
ically compress  the  blood-vessels,  and  when  abundant  they  maj'^  occlude 
vascular  trunks  or  their  branches.  In  the  fissure  of  Sylvius  and  in  the 
region  of  the  circle  of  Willis  we  are  apt  to  find  the  most  abundant  de- 
])osit  of  tubercle,  although  they  may  also  be  scattered  here  and  .there 
along  the  vessels  upon  the  convexity  of  the  brain.  I  have  observed 
them  also  in  the  longitudinal  fissure,  and  upon  the  cerebellum  and  spinal 
meninges. 

The  amount  of  tnbercnlar  deposit  varies  between  extreme  limits.  If 
very  abundant,  the  vessels  may  be  completely  imbedded  in  them;  again, 
the}'  may  be  so  scattered  as  to  give  to  individual  vessels  an  appearance 
of  localized  swellings,  which  has  been  compared  to  a  "string  of  beads;" 
finally,  they  may  in  some  cases  be  overlooked  by  a  casual  observer  on 
account  of  their  scarcit}'. 

The  elfects  of  partial  or  complete  occlusion  of  cerebral  vessels  by 
tubercular  deposits  may  be  manifested  (1)  by  multiple  hemorrhages  from 
collateral  fluxion;  (2)  b}^  spots  of  red  softening;  and  (3)  hy  effusions  of 
serum  into  the  ventricles  and  at  the  base  of  the  brain. 

The  tuberculous  masses  are  found  in  this  disease  to  exist  in  all 
stages  of  development.  Some  may  appear  as  large  as  a  small  pea, 
from  a  confluence  of  smaller  nodules ;  others  may  scarcely  be  visible 
to  the  naked  eye;  finall3^  some  may  be  seen  to  have  undergone  granu- 
lar and  caseous  degeneration.  Under  the  microscope,  normal  tubercle 
appears  as  small  gra3'ish-white,  semi-transparent,  and  partly  gelatinous 
bodies. 

A  well-marked  injlamiinatory  exudation  is  found  in  addition  to  the 
deposit  of  tubercle  at  the  base  of  the  brain.  This  may  consist  of  serum 
alone,  which  is  usually  more  or  less  turlnd  ;  or  it  may  appear  as  a  yellowish 
sero-fibrinous  layer  which  is  most  apparent  about  the  Sylvian  fissure,  and 
along  the  course  of  the  larger  blood-vessels.  It  may  cover  the  entire  base 
of  the  brain,  extending  even  to  the  under  surface  of  the  cerebellum.  The 
])ia  will  be  found  to  have  lost  its  lustre  and  to  be  thickened,  opaque,  and 
inelastic.     It  is  more  easily  torn  than  in  health.     Finall}-,  the  ventricles 


ACUTE   HYDKOCEPHALUS.  305 

are  found  to  be  dilated,  and  to  contain  a  serous  effusion.  The  linino; 
membrane  (epenclyma)  is  thickened.  The  descending  horn  of  the  lateral 
ventricle  is  particularly  liable  to  become  overdisteuded.  The  exudation 
into  the  ventricles  may  be  purulent,  in  rare  instances.  As  a  rule,  it  con- 
sists of  a  serous  fluid  which  is  more  or  less  turbid  from  an  admixture  of 
white  blood-corpuscles  and  epithelium.  Tubercles  may  be  often  detected 
in  the  ependyma,  and  along  tlie  vessels  of  the  choroid  plexus. 

The  ertusion  within  the  ventricles,  if  large  in  amount,  may  exert 
pressure  upon  the  convolutions  of  the  cerebrum,  and  thus  cause  them  to 
appear  more  or  less  flattened  and  distorted.  The  brain-substance  may 
also  appear  dryer  than  normal,  on  account  of  an  anaemia  that  has  been 
similarly  produced. 

In  closing  my  remarks  upon  the  morbid  anatomy  of  this  disease  let 
me  remind  the  reader  that  all  the  typical  changes  mentioned  ma}-  not 
exist,  in  each  case.  The  yellowish  deposit  at  the  base  of  the  brain  may- 
be absent ;  the  distension  of  the  ventricles  forms  an  insignificant  lesion 
in  some  cases,  and  may  even  escape  detection ;  finally,  the  deposit  of 
tubercle  may  be  very  slight  and  limited  in  extent,  or,  again,  it  may  be 
detected  everywhere,  even  in  the  substance  of  the  brain  itself. 

Tuberculous  meningitis  is  associated  in  many  cases  with  the  patho- 
logical manifestations  of  general  tuberculosis.  It  is  well,  therefore,  to 
examine  the  viscera  of  the  thorax  and  abdomen  as  well  as  the  spinal  cord 
at  every  autopsy. 

Etiology. — Between  the  first  and  seventh  3-ear,  children  of  a  tuber- 
cular diathesis  are  particularly  prone  to  develop  this  disease.  It  may 
occur  also  from  acquired  tuberculosis,  which  follows  infection  from 
caseous  matter,  etc.  This  probably  accounts  for  its  occasional  presence 
in  adults.  It  may  accompany  general  tuberculosis  as  one  of  its  manifes- 
tations. 

Among  the  exciting  causes  maj^  be  mentioned  any  of  the  exhausting 
diseases,  such  as  the  fevers,  diarrhoea,  etc. ;  injuries  to  the  head  ;  den- 
tition ;  otitis  media ;  eruptions  of  the  face  or  scalp ;  and  improper 
nourishment  and  h3^giene. 

These  causes  may  occasionally  produce  the  so-called  "  lepto-menin- 
gitis  "  described  by  Huguenin,  in  which  all  the  morbid  changes  described 
except  the  presence  of  tubercles  are  found. 

Large  and  densely  populated  cities  exhibit  a  greater  mortality  in 
children  from  this  cause  than  the  rural  districts  of  smaller  towns. 
Children  who  are  not  suckled,  and  who  live  in  poorly-lighted  and 
imperfectly-warmed  apartments,  are  ver^'  apt  to  develop  an  impairment 
of  the  physical  powers.  This  often  leads  to  glandular  swellings,  the 
development  of  hydrocephalus,  and  other  manifestations  of  tuberculosis 
or  scrofula. 

20 


306  LECTURES   ON    NERVOUS   DISEASES. 

Acute  liydrooei)haliis,  when  it  attacks  adults,  is  most  often  encoun- 
tered  between  the  twentieth  and  fortieth  years.  Males  are  more  often 
attacked  than  women. 

Symptoms. — These  will  vary  with  the  pathological  changes  which 
have  occurred.  Enough  has  been  said  already  respecting  the  lesions 
found  iu  the  brain  after  death  to  show  the  basis  of  this  deduction.  The 
extent  and  amount  of  the  basilar  exudation,  and  the  amount  of  fluid 
poured  into  the  ventricles  will  determine  the  course  of  the  disease  and 
its  sj'mptoms  rather  than  the  presence  or  absence  of  tubercle. 

The  advent  of  acute  hydrocephalus  may  be  A'ery  insidious  or  A-er}' 
rapid.  The  former  method  of  attack  is  observed,  as  a  rule.  The  latter 
method  of  onset  is  frequently  attended  with  convulsions. 

It  is  a  custom  with  some  authors,  although  serious  objections  can 
be  advanced  against  it,  to  divide  the  symptoms  of  this  form  of  menin- 
gitis into  those  of  distinct  stages.  Thus  Huguenin  speaks  of  a  stage  of 
irritation,  a  second  of  pressure,  and  a  third  of  paralysis.  Examples  of 
a  similar  kind  might  be  cited  from  other  authorities.  Xow,  while  this 
maj'  be  desirable  from  an  author's  point  of  view  for  beginners,  the  excep- 
tions to  any  type  presented  are  so  frequent  as  to  almost  disprove  the 
rule. 

The  premonitory  symptoms  (when  the  advent  is  gradual)  are  such  as 
may  attract  the  notice  of  the  nurse  or  parents.  The  child  becomes 
peevish  and  irritable,  is  observed  frequenth'  to  stop  in  its  play  and  rest 
the  head  upon  the  hands  or  floor,  or  upon  the  knee  of  the  mother ;  it 
gradually'  becomes  dull  and  apathetic,  and  desires  to  remain  quiet ;  it 
sleeps  in  a  restless  manner ;  the  appetite  becomes  very  capricious ;  the 
tongue  may  be  coated  ;  the  breath  is  apt  to  be  offensive,  and  constipation 
often  alternates  with  diarrhoea.  Progressive  emaciation  of  the  body  and 
limbs  takes  place.  This  is  a  symptom  of  diagnostic  importance,  when 
it  is  accompanied  by  those  previouslv  mentioned.  The  temperature  of 
the  body  may  rise  slightly  in  the  evening.  Sometimes  a  hacking  cough 
may  be  developed.  The  countenance  of  the  child  is  apt  to  lose  its  expres- 
sion of  vivacity,  and  to  become  dull  and  immobile.  Pallor  is  usually  de- 
veloped. Transient  attacks  of  flushing  of  the  face  may  be  observed,  but 
the}'  are  of  short  duration.     Headache  is  not  common. 

These  prodromata  ma}-  last  only  a  few  da3-s  in  some  subjects,  while 
in  others  they  may  persist  for  weeks. 

First  Stage. — This  stage  gives  clinical  evidence  of  cerebral  irrita- 
tion. The  advent  of  the  disease  is  marked  by  a  variety  of  symptoms  of 
a  more  marked  character  than  the  prodromata.  Vomiting  is  frequently 
dcA-eloped.  It  ma}'  be  very  persistent  and  projectile  in  character.  Head- 
ache is  also  complained  of  by  the  child.  It  is  very  severe  as  a  rule,  and 
causes  the  sufferer  to  cry  and  ,put  the  hands  to  the  head.     It  is  not 


ACUTE  HYDEOCEPHALUS.  307 

constant,  and  is  usually  confined  to  the  frontal  region.  It  may  prevent 
protracted  sleep  and  cause  paroxysms  of  screaming. 

In  some  instances,  the  onset  of  this  disease  is  marked  by  convulsions 
of  an  epileptic  character.  In  these  cases  the  prodromata  may  have 
been  absent. 

During  sleep  the  child  flexes  the  thumbs  upon  the  palms  of  the 
hands,  grinds  the  teeth  together,  and  rolls  the  head  from  side  to  side  or 
bores  it  into  the  pillow.  It  often  awakes  during  sleep  with  the  so-called 
"  hydrocephalic  cr}^,"  and  spasmodic  movements  of  the  ocular  and  facial 
muscles  are  sometimes  observed. 

Now,  when  we  examine  such  a  child  with  care,  we  shall  see  that  the 
abdomen  is  retracted,  hard,  and  "  boat-shaped  ;"  that  the  pupils  are  small ; 
that  the  skin  of  the  abdomen  or  thorax  will  show  a  red  line  in  about 
thirty  seconds  after  the  finger-nail  has  been  drawn  across  it  (tache  cere- 
bral of  Trousseau)  ;  that  pressure  upon  the  fontanelle,  in  a  very  young 
child,  will  increase  the  symptoms  of  cranial  pain  ;  that  the  tongue  is  dry 
and  coated  except  at  the  edges  and  tip,  which  are  generally  red  ;  that 
there  is  photophobia,  and  often  strabismus  ;  and  that  the  thermometer 
shows  a  marked  elevation  of  temperature  which  exhibits  evening  exacer- 
bations and  morning  remissions  of  about  two  degrees. 

The  temj)erature  rarely  rises  above  103°  F.  It  may  not  exceed 
101°  F.  When  convulsions  appear  at  the  onset,  it  may  go  two  or  thrc/j 
degrees  higher.  The  exacerbations  and  remissions  of  the  fever  are  not 
as  regular  as  in  some  other  forms  of  disease. 

The  pulse  is  increased  in  frequency,  but  is  regular,  full  in  volume, 
and  compressible,  except  upon  excitement  or  muscular  exertion.  It  may 
then  be  somewhat  irregular. 

In  some  cases,  the  breathing  may  be  somewhat  irregular ;  but  as  a 
rule  the  rhythm  is  normal. 

The  restless  and  fitful  sleep  gradually  gives  place  to  an  increasing 
drowsiness.     The  child  sleeps  constantly  unless  aroused. 

The  duration  of  this  stage  is  usually  about  a  week.  It  may,  however, 
be  prolonged  to  ten  or  even  fourteen  days. 

Second  Stage. — When  the  brain  begins  to  exhibit  the  clinical  evi- 
dences of  depression  (as  a  result  of  effusion  into  the  ventricles  and  at  the 
base  of  the  skull)  the  symptoms  of  invasion  disaj^pear  and  new  ones 
take  their  place. 

The  pupils,  which  were  contracted,  now  begin  to  dilate  irregularly. 
They  respond  slowly  to  light.  The  head  becomes  forcibly  extended  b}'" 
a  tonic  rigidity  of  the  muscles  of  the  neck  so  that  it  bores  into  the  pillow. 
Sometimes  the  muscles  of  the  back  contract  so  forcibly  as  to  cause  opis- 
thotonos. Muscular  spasms  and  paroxysms  of  delirium  are  developed. 
In  some  instances,  the  patient  lies  motionless  upon  the  back,  with  the  e3'es 


308  LECTURES   ON   NERVOUS   DISEASES. 

Staring  fixedly  and  unconscious  of  surrounding  objects.  The  projectile 
vomiting  of  tlie  first  stage  ceases.  The  urine  and  lieces  may  be  passed 
involuntarily. 

The  muscles  show  the  effects  of  cerebral  disturbance  in  various 
ways.  We  have  already  alluded  to  the  tonic  spasm  of  the  back  muscles. 
The  muscles  of  the  upper  extremity  are  usually  thrown  into  a  state  of 
excitability,  as  shown  by  a  perpetual  movement  of  the  fingers,  picking 
of  the  bed-clothes,  opening  and  shutting  of  the  hands  in  an  aimless  way, 
etc.  General  convulsions  may  occur  from  time  to  time.  The  ocular 
muscles  may  be  affected.  When  so,  the  third  cranial  nerve  and  also  the 
optic  chiasm  or  the  optic  tracts  are  apt  to  be  simultaneously  involved. 
We  are  liable  to  encounter  nystagmus,  strabismus,  ptosis,  and  pupillary 
spasm  in  such  cases.  Sometimes  the  facial  nerve  may  be  involved,  and 
facial  spasm  or  paralysis  may  then  ensue.  1  recall  an  instance  where 
the  disease  was  associated  with  otitis  media,  in  which  the  onset  was 
accompanied  by  facial  pais}'. 

The  temperature  of  the  body  falls  during  this  stage.  It  may  reach 
the  normal  point. 

The  headache  appai-ently  persists  in  this  stage,  although  the  patient 
does  not  complain  of  it.  We  are  justified  in  drawing  this  deduction 
from  the  fact  that  these  subjects  utter  at  intervals  a  peculiar  cry,  known 
as  the  "  hydrocephalic  cry."  It  seems  to  be  partly  involuntary  and  to 
express  both  alarm  and  pain.  The  facial  muscles  assume  the  attitude 
expressive  of  pain  when  tlie  cry  takes  place. 

The  respiration  becomes  more  or  less  irregular  during  this  stage. 
In  some  instances  I  have  observed  typical  "  Cheyne-Stokes  breathing." 
These  symptoms,  as  well  as  disturbances  of  the  heart's  action  and  im- 
pairment of  the  power  of  swallowing,  which  often  exist,  indicate  that  the 
pneumogastric  nerves  are  involved. 

The  ophthalmoscope  may  enable  us  to  detect  infiltration  about  the 
papilla,  varicosities  of  the  veins  of  the  retina,  small  punctate  hemor- 
rhages, and  whitish  granulations  of  the  choroid  and  retina  in  some 
instances.     A  choked  disk  has  been  observed  also. 

The  urine  may  contain  albumen.  It  is  usually  high-colored,  scanty, 
and  abundantly  impregnated  with  chlorides  and  phosphates. 

The  faeces  are  often  slimy,  and  are  greenish  in  color,  and  very  offen- 
sive in  the  large  majority  of  cases. 

The  tongue  becomes  covered  with  incrustations,  in  which  changes  the 
lips  and  gums  may  also  participate. 

Some  years  ago,  my  attention  was  called  to  the  fact  that  the  second 
stage  of  this  disease  is  often  accompanied  by  a  short  interval  of  apparent 
convalescence.  The  patient  may  regain  consciousness,  be  free  from  de- 
lirium or  pain,  eat  voraciously,  and  excite  the  belief  that  recovery  has 


ACUTE   HYDROCEPHALUS.  309 

begun.  But,  in  my  experience,  these  intervals  are  of  short  duration,  and 
the  patient  passes  after  a  hxpse  of  a  few  hours  into  deep  coma  again. 

Finally,  hemiplegia  may  occasionally  be  developed.  It  indicates 
pressure  upon  the  motor  tracts  which  join  the  cells  of  the  cerebrum  with 
those  of  the  anterior  horns  of  the  spinal  cord.     (See  page  258.) 

Thii-d  Stage. — This  is  characterized  by  an  increasing  intensity  of 
the  symptoms  of  the  second  stage,  with  an  exacerbation  of  the  febrile 
sj^mptoms  of  the  first  stage.  Huguenin  calls  it  the  "  stage  of  paralysis," 
because  that  S3'mptom  is  a  very  prominent  one.  Hammond  names  it  the 
"  stage  of  recurrence,"  because  the  febrile  symptoms  return  and  the  cere- 
bral disturbance  is  more  profound. 

We  observe,  during  this  stage,  the  development  of  a  paralysis  of  some 
part  of  the  body,  which  is  permanent.  Convulsions  and  contracture  of 
the  muscles  of  the  back,  neck,  and  jaw  may  precede  the  paralysis. 
Reflex  movements  can  be  excited  in  the  paralyzed  limbs,  although  the 
power  of  voluntary  motion  is  lost.  The  face,  e3'es,  or  limbs,  may  be  the 
seat  of  paralysis.     It  is  probably  due  to  excessive  intra-cranial  pressure. 

The  temperature  rises  higher  than  it  did  in  the  first  stage.  I  have 
observed  it  to  reach  10T°  F.,  in  one  instance,  a  few  hours  before  death 
occurred.     It  often  rises  to  105°  F. 

The  pulse  becomes  greatly  accelerated,  small  in  volume,  and  intermit- 
tent. It  resembles  the  pulse  observed  in  animals  after  section  of  the  vagus. 

Coma  becomes  profound.  It  is  accompanied  by  a  clammy  sweat, 
involuntary  evacuations,  dysphagia,  dilated  pupils,  stertorous  breathing, 
a  tympanitic  abdomen,  and  paralysis. 

Death  usually  occurs  from  asph3'xia,  or  convulsions.  It  may  ensue 
from  impairment  of  the  heart's  action. 

Duration  of  the  DUease. — This  admits  of  the  widest  latitude  of 
statement.  Cases  have  been  reported  where  death  has  occurred  in  a  few 
hours,  while  others  have  lasted  for  many  weeks. 

Those  which  begin  with  paralyses  or  convulsions  are  rapidly  fatal, 
in  my  experience. 

The  age  of  the  patient  may  modify  the  duration  of  the  disease. 
While  I  believe  that  no  pathological  differences  exist  between  the  infan- 
tile and  adult  varieties  of  the  disease,  its  duration  is  more  apt  to  be 
abnormally  short  in  the  child.  When  it  develops  as  a  complication  of 
general  tuberculosis,  death  often  occurs  during  the  first  week.  A  vigor- 
ous constitution  may  cause  the  disease  to  be  prolonged  over  a  much 
longer  period.  The  vague  character  of  the  prodromal  symptoms  in 
many  cases  renders  it  advisable  to  count  the  duration  of  the  disease 
from  the  first  well-marked  cerebral  symptom. 

Differential  Diagnosis.— In  common  with  many  other  observers,  I 
have  seen  cases  of  acute  hydrocephalus  which  have  resembled  those  of 


310  "LECTURES   ON  NERVOUS  DISEASES. 

acute  Bright's  disease,  infantile  remittent  fever,  acute  meningitis,  gastro- 
enteritis, and  typlioid  fever.  A  condition  called  "  spurious  hydrocepha- 
lus," which  develops  in  children,  may  also  closely  resemble  it  in  many 
respects. 

The  acute  form  of  BnghVs  disease  is  to  be  distinguished  by  the  pres- 
ence of  albumen  and  casts  in  the  urine,  the  existence  of  oedema  of  the 
face  and  limbs,  the  peculiar  waxy  skin  of  ura;mic  poisoning,  and  the 
absence  of  the  prodromal  symptoms  of  hydrocephalus.  The  history  of 
the  case  may  also  afford  a  clue  to  the  cause  of  the  attack. 

Infantile  remittent  fever  is  accompanied  by  a  very  high  range  of 
temperature  (105°-106°  F.),  which  exhibits  regular  remissions  and  ex- 
acerbations. It  exceeds  the  customary  limits  of  the  fever  of  hydro- 
cephalus (103°  F.),  and  does  not  fluctuate  irregularly.  The  pupils  are 
normal.  The  pulse  does  not  intermit  or  become  irregular.  The  hydro- 
cephalic cry  is  not  developed,  nor  are  the  thumbs  flexed  upon  the  palms 
during  sleep.  The  patient  does  not  grind  the  teeth.  The  vomiting  is 
not  projectile  in  character;  it  is  accompanied  by  retching.  The  abdo- 
men is  distended  with  gas,  and  is  tender.  "  Pea-soup  discharges  "  from 
the  bowels  occur. 

Acute  meningitis  is  less  frequentlj^  accompanied  by  ocular  symp- 
toms, and  a  retracted  and  "  boat-shaped  "  abdomen.  It  does  not  produce 
the  hydrocephalic  cry,  nor  any  of  the  prodromata  of  the  tubercular 
variety.  It  is  a  disease  of  sudden  onset  and  rapid  progress.  The  tem- 
perature runs  high,  and  exhibits  very  slight  remissions.  The  pulse  is 
not  irregular  except  when  death  is  near.  It  attacks  adults  and  children 
in  o-ood  health.  Delirium  and  convulsions  occur  earlier  than  in  the 
tubercular  form. 

Gastro-enferitis  fails  to  produce  the  prodromata  of  tubercular 
meningitis,  and  also  headache,  projectile  vomiting,  hydrocephalic  cr}', 
paralyses,  irregular  pulse,  etc.  It  is  associated  with  diarrhoea,  tenderness 
of  the  abdomen,  and  pain  in  the  bowels. 

Typhoid  fever  is  accompanied  by  diarrhoea,  tympanites,  a  character- 
istic eruption  upon  the  abdomen,  and  a  t.ypical  range  in  temperature. 
The  prodromata  of  hydrocephalus,  and  the  more  prominent  S3-mptoms 
of  that  disease  mentioned  above  are  wanting. 

Spurious  hydrocephalus  usually  follows  an  attack  of  cholera  infan- 
tum. It  is  sometimes  accompanied  by  a  few  of  the  cerebral  manifesta- 
tions of  the  tubercular  variety,  but  the  abdomen  is  distended  and  tender, 
the  fontanelle  is  depressed,  paralyses  do  not  occur,  and  the  temperature 
and  pulse  do  not  indicate  the  more  serious  affection. 

Prognosis.  —  Tuberculosis  of  the  meninges  and  brain  generally 
terminates  in  death.  So  large  is  the  percentage  of  mortality  that 
most  authors  deny  that  a  case  of  recovery  has  ever  occurred.     On  the 


ACUTE   HYDKOCEPHALUS.  311 

other  hand,  isolated  cases  of  apparent  recovery  have  been  reported  hy 
Formey,  Folitzer,  Rilliet,  Hahn,  Barthez,  and  others.  Personally,  I  have 
never  seen  a  case  where  recovery  has  taken  place,  and  I  am  inclined  to 
believe  that  lepto-meningitis  has  existed  in  all  cases  where  a  favorable 
result  has  occurred.  It  is  certain  that  idiocy,  epilepsy,  and  the  chronic 
type  of  hydrocephalus  is  dependent  upon  a  tubercular  diathesis  in  some 
instances ;  but  it  is  not  yet  proven  that  they  have  ever  been  preceded  by 
a  typical  attack  of  acute  hydrocephalus. 

Treatment. — M3-  remarks  made  concerning  the  prognosis  of  this 
disease  must  preclude  any  suggestions  relative  to  a  cure  of  th'is  atl'ection. 
I  have  tried  all  the  methods  of  treatment  suggested  by  authors,  including 
the  iodide  of  potash,  the  mercurial  salts,  the  phosphate  of  soda,  depletion, 
etc.,  without  any  apparent  benehts.  Is  otwithstanding  the  incurability  of 
the  disease,  the  individual  symptoms  should  be  ameliorated,  however, 
as  long  as  life  exists,  by  judicious  medication.  The  preparations  of 
opium  and  the  bromide  salts  are  indicated  when  headache,  photophobia, 
restlessness,  and  jactitation  are  present.  Ice-bags  may  often  be  applied 
to  the  head  with  apparent  benefit.  The  bowels  should  be  moved  by 
laxatives  when  constipation  exists.  The  patient  should  be  kept  in  a 
quiet  and  darkened  room.  When  the  convulsive  attacks  are  frequent 
and  severe,  I  occasionally  administer  anaesthetics.  Venesection  or  local 
depletion  is  of  no  benefit,  and  should  not  be  performed. 

The  prophylactic  treatment  of  this  malady  deserves  more  considera- 
tion than  is  often  paid  to  it  by  medical  men.  I  am  convinced  that  I  have 
saved  the  lives  of  many  children  born  of  tubercular  parents  by  the  steps 
which  I  shall  here  advise. 

It  is  m}'  custom,  with  children  who  are  predisposed  to  this  affection, 
to  insist  that  the  child  shall  be  nursed  from  birth  by  a  woman  who  is  free 
from  all  hereditary  or  acquired  diseases.  The  child  should  be  kept  in 
the  country  and  allowed  to  romp  in  the  open  air  until  seven  years  old. 
The  hygienic  surroundings  and  the  diet  of  the  child  should  also  be  care- 
fully looked  to  until  the  period  of  danger  has  passed.  It  is  my  custom 
to  administer  cod-liver  oil  to  those  who  remain  thin  or  poorly  nourished 
in  spite  of  the  precautions  mentioned.  Bathing  the  body  in  cool  water, 
and  subsequent  frictions  of  the  skin  are  of  benefit.  It  is  also  well  to 
change  the  climate  and  surroundings  frequently,  so  as  to  avoid  unneces- 
sary exposure  to  cold  or  dampness  during  the  winter  months,  or  to 
extreme  heat  in  the  summer.  By  these  means  many  children  are  reared 
to  adult  life  when  previous  oH'spring  of  the  same  parents  have  died 
of  hydrocephalus. 

I  would  caution  the  reader  also  against  allowing  children  with  hered- 
itary tendencies  to  tuberculosis  to  be  subjected  to  extreme  or  prolonged 
excitement  of  any  kind.     It  is  not  well  to  send  them  to  school  until  the 


312  LECTURES   ON   NERVOUS   DISEASES. 

period  of  danger  has  passed.  I  am  convinced  that  playing  with  children 
before  going  to  bed,  especially  if  impressionable  or  emotional,  conduces 
to  imperfect  sleep  and  physical  debility.  The  custom  of  forcing  the 
young  intellect  b}'  feats  of  memory  or  confinement  in  the  school-room  is 
also  very  pernicious. 

The  proportion  of  shalloiv  orbiti^  and  hyperopic  eyes  in  persons  who 
have  a  tul)er(*ulous  ancestry  is  very  large,  as  proven  by  the  examination 
of  many  hundreds  of  cases  by  my  friend  Dr.  G.  T.  Stevens.  My  own 
observations  (lately  published  in  a  paper  read  b^^  me  before  the  Inter- 
national Medical  Congress,  1888)  confirm  this  statement,  and  lead  me  to 
believe  that  "latent  hypermetropla  "  (p.  127)  is  remarkabl}-  frequent  in 
this  class  of  subjects.  This  congenital  defect  (if  it  exists)  should  be 
properly  corrected  by  glasses  before  the  child  is  allowed  to  study.  I 
have  no  doubt  tliat  this  one  factor  has  more  to  do  with  the  so-called 
"  tuberculous  predisposition  "  than  many  of  us  imagine.  The  health  of 
any  child  must  of  necessity  be  seriouslj^  affected  by  this  well-recognized 
source  of  physical  disturbance  and  excessive  nervous  expenditure. 

CHRONIC   HYDROCEPHALUS. 

This  disease  is  essentially  surgical ;  the  acute  form  comes  more 
particularly  under  the  province  of  the  physician.  In  either  case,  how- 
ever, the  "tubercular  diathesis"  seems  to  influence  its  development. 

Chronic  hydrocephalus  appears  to  be  produced  by  a  low  grade  of 
inflammation  which  attacks  the  lining  of  the  ventricles  during  foetal  life 
or  early  childhood.  In  some  instances,  it  appears  later  in  life.  In  a  few 
isolated  cases,  the  serous  efl"usion  seems  to  be  external  to  the  brain.  Some 
authors  state  that  this  latter  condition  never  occurs  except  as  the  result 
of  a  hemorrhage  into  the  cavity  of  the  arachnoid.  They  consider  the 
condition  which  stimulates  true  external  hydrocephalus  as  an  evidence 
either  of  a  congenital  defect  in  development  (the  cerebro-spinal  fluid 
taking  the  place  which  the  brain  should  have  occupied),  or  of  atrophy 
of  the  brain-substance  that  has  resulted  from  the  pressure  of  the  fluid 
within  the  ventricles. 

Morbid  Anatomy. — In  chronic  hydrocephalus,  the  sutures  fail  to  unite 
and  the  calvaria  does  not  ossify  as  in  health.  The  ventricles  are  enor- 
mously distended,  and  the  channels  of  communication  between  them  are 
widely  dilated  and  open.  Finally,  the  convolutions  are  flattened  and  the 
cerebral  substance  rendered  extremely  thin  and  attenuated.  The  ossa 
triqnetra  are  often  found  to  be  excessive.  A  complicating  meningitis 
(which  often  exists)  may  involve  some  of  the  cranial  nerves  (especially 
the  optic)  and  induce  atrophy  of  them.  Fluctuation  ma}^  be  detected 
often  in  the  region  of  the  fontanelles  and  the  open  sutures. 

The  deformity  of  the  cranium  is  evidenced  by  an  overhanging  brow, 


CHKONIC   HYDKOCEPHALUS. 


313 


an  increase  of  the  circumference  of  the  cranium  and  its  disproportion  to 
tiie  size  of  the  face,  and  by  open  fontanelles  and  unclosed  sutures.  The 
hitter  are  often  widely  separated.  The  mental  condition  of  the  subject 
is  below  the  normal  standard  whenever  the  pressure  of  the  fluid  has 
induced  changes  in  the  brain-substance. 

Instances  have  been  reported  where  twenty  or  more  pounds  of  fluid 
have  been  found  to  exist  within  the  skull.  The  circumferential  measure- 
ment of  the  head  has  been  known  to  exceed  forty  inches. 

The  fluid  formed  diirinsr  the  progress  of  this  disease  consists  of  water, 
albumen,  flocculi  of  lymph,  salts  of  lime,  soda,  and  potash,  epithelial  and 
blood  cells,  and  urea. 


Fig.   R4 — Chronic  Hydrocephalus.     (After  a  photograph.) 

The  condition  of  the  brain-substance  found  after  death  depends 
upon  the  seat  and  extent  of  the  dropsical  effusion.  It  may  be  softened 
and  atrophied,  when  degeneration  has  been  produced  b}-  a  pressure  which 
lias  impaired  its  blood-supply.  Occasionally  it  is  rendered  abnormally 
resistant  and  of  firm  consistence. 

Etiology. — The  hereditary  nature  of  this  affection  is  proven  by  the 
fact  that  seA'eral  children  of  the  same  [larentage  have  been  successively 
attacked  in  many  recorded  instances. 

The  acquired  form  may  be  independent  of  any  hereditary  taint.  It 
has  been  observed  to  accompany  congenital  defects  of  the  walls  of  the 
blood-vessels,  chronic  passive  hyperemia,  occlusion  of  the  cerebral 
sinuses,  rickets,  syphilis,  alcoholism,  some  of  the  eruptive  fevers,  and 


314  LECTURES   ON   NERVOUS   DISEASES. 

atroi)h3'  or  imperfect  development  of  the  brain.  Aged  subjects  may 
sometime-  be  attacked.  In  the  young,  it  is  frequently  developed  during 
or  previous  to  dentition. 

Symptoms.— The  deformity  of  the  head,  which  is  characteristic  of 
this  disease,  may  occasionally  be  present  at  birth.  As  a  rule,  however, 
the  increase  in  the  size  of  the  head  does  not  manifest  itself  until  the 
child  is  a  month  or  two  old.  If  it  exists  at  birth,  the  child  is  apt  to  die 
soon  after  delivery. 

Whenever  the  deformity  becomes  well  developed,  it  seems  to  me 
impossible  for  a  medical  man  to  err  in  diagnosis. 

The  countenance  of  chronic  hydrocephalus  (see  fig.  84)  is  perhaps  the 
most  typical  of  any  of  the  conditions  to  which  the  attention  of  the  ph^'- 
sician  or  surgeon  is  directed.  In  it,  the  frontal  bone  is  tilted  forward  so 
that  the  forehead,  instead  of  slanting  a  little  backward,  rises  perpendicu- 
larly, or  even  juts  out  at  its  upper  part,  and  overhangs  the  brow.  Watson 
thus  describes  it :  "  The  parietal  bones  bulge,  above,  toward  the  sides ;  the 
occiput  is  pushed  backward,  and  the  head  becomes  long,  broad,  and  deep, 
but  flattened  on  the  top.  This,  at  least,  is  the  most  ordinary  result.  In 
some  instances,  however,  the  skull  rises  up  in  a  conical  form  like  a  sugar- 
loaf.  Not  unfrequently  the  whole  head  is  irregularly  deformed,  the  two 
sides  being  unsymmetrical.  Some  of  these  rarer  varieties  of  form  are  fixed 
and  connate ;  others  are  owing,  probably,  to  the  kind  of  external  pressure 
to  which  the  head  has  been  subjected.  While  the  skull  may  be  rapidly 
enlarging,  the  bones  of  the  face  grow  no  faster  than  usual,  perhaps  not 
even  so  fast,  and  the  disproportion  that  results  gives  an  odd  and  peculiar 
physiognom}"  to  the  unhappy  subjects  of  this  calamity.  They  have  not 
the  usual  round  or  oval  face  of  childhood.  The  forehead  is  broad,  and 
the  outline  of  the  features  tapers  toward  the  chin.  The  visage  is  triang- 
ular. The  great  disproportion  in  size  between  the  head  and  the  face  is 
diagnostic  of  the  disease,  and  would  serve  to  distinguish  the  skull  of  the 
hydrocephalic  child  from  that  of  a  giant." 

As  a  result  of  the  compression  and  atrophy  of  the  brain,  the  limbs 
do  not  develop  as  in  health,  the  abdomen  is  usually  distended  and  tym- 
panitic, the  child  is  unable  to  hold  the  head  erect,  and  the  pupils  become 
more  or  less  dilated.  Sometimes  the  eyes  bulge  from  their  sockets.  At 
the  fontanelles  and  open  sutures  fluctuation  may  be  detected  when  the 
dropsical  eff"usion  is  external  to  the  brain. 

The  digestive  functions  are  carried  on  imperfectly  during  hydroceph- 
alus. Hence  these  children  exhibit  inanition,  and  are  prone  to  develop 
some  form  of  inter-enrrent  disease.  I  have  seen  instances  where  death 
has  occurred  from  starvation. 

In  a  certain  proportion  of  cases,  life  maybe  prolonged  for  years.  It 
will  then  be  observed  that  the  power  of  walking  is  acquired  imperfectly 


CHKONIC   HYDEOCEPHALUS.  315 

and  late.  The  gait  is  cliaracterized  by  tottering,  stumMing,  and  a 
peculiar  awkwardness  of  movement  indicative  of  idiocy.  Tlie  mental 
powers  are  more  or  less  impaired.  These  subjects  are  generally  \evy 
irritable  and  peevish,  and  are  liable  to  have  recurring  attacks  of  fever, 
nausea,  and  vomiting.  Convulsions  are  frequent,  and  paral}- sis  of  special 
groups  of  muscles  may  be  developed  during  the  progress  of  the  disease. 

I  have  personally  seen  one  hydrocephalic  subject  who  lived  to  be 
over  thirty  years  of  age.  It  is  not  common,  however,  for  life  to  be  pro- 
longed to  such  extreme  limits.  The  majority  die  within  three  or  four 
years.  Whenever  ana?mia  or  asthenia  are  induced,  the  patient  dies  within 
a  period  of  twelve  months,  as  a  rule. 

Differential  Diagnosis. — Little  need  be  said  regarding  the  diagnosis 
of  this  disease.  It  can  hardly  be  confounded  with  any  other  atlection. 
Although  the  cranial  deformity  of  rickets  produces  a  lack  of  symmetr}'  in 
the  contour  of  the  head,  the  open  sutures,  the  sense  of  fluctuation,  and  the 
characteristic  deformity  of  hydrocephalus  do  not  exist,  nor  are  mental 
and  physical  derangements  similar  to  those  of  hydrocephalus  induced. 

Prognosis. — The  large  majority  of  these  subjects  die  within  one  3  ear. 
The  exciting  causes  of  death  include  the  following  complications  :  Men- 
ingitis, apoplexy,  ependj-mitis,  ansemia,  asthenia,  paralysis  of  the  heart, 
and  escape  of  the  fluid  by  rupture  of  the  aponeurosis  covering  the  skull 
and  open  sutures.  When  recovery  takes  place,  the  fluid  ceases  to  form 
and  the  sutures  gradually  close. 

Treatment. — Suggestions  both  of  a  medical  and  surgical  character 
have  been  brought  forward  from  time  to  time  as  productive  of  good  in 
this  disease ;  but  I  have  laid  most  of  them  aside,  as  I  have  found  them  of 
doubtful  utility.  Occasionally,  it  is  well  to  strap  the  head.  I  doubt  if 
the  exudation  within  the  skull  was  ever  arrested  by  mechanical  compres- 
sion ;  but  it  sometimes  appears  to  give  ease  to  the  patient,  and  it  inva- 
riably gratifies  tlie  parents  and  interested  friends. 

Tapping  of  the  head  may  be  employed  with  advantage  when  fluctu- 
ation can  be  detected  at  the  fontanelles.  It  is  contra-indicated  when 
inflammatory  changes  are  present.  The  aspirating  needle  should  be  in- 
troduced at  the  anterior  fontanelle,  and  a  few  ounces  of  fluid  only  should 
be  withdrawn  at  one  time.  The  head  should  be  bandaged  after  the  oper- 
ation, and  the  child  carefully  watched  for  inflammatory  sequelae.  Lan- 
genbeck  has  employed  aspiration  of  the  lateral  ventricle  (by  passing  an 
aspirating  needle  through  the  roof  of  the  orbit  behind  the  upper  eyelid) 
in  the  internal  variety  of  chronic  hydrocephalus.  I  have  never  resorted 
to  this  method  of  treatment,  because  I  regard  it  as  a  dangerous  one  and 
of  questionable  benefit  to  the  patient. 

The  medicinal  treatment  of  this  disease  must  be  purely'  sj^mptomatic. 
It  is  well  to  administer  tonics,  such  as  cod-liver  oil,  the  iodide  of  iron, 


316  LECTURES     ON     NERVOUS     DISEASES. 

and  quinine,  at  intervals  tlirouirhout  the  course  of  the  disease.  Some 
authorities  recommend  the  iodide  of  potash.  Calomel  in  minute  doses 
(gr.  ^-^  daily)  may  be  employed  until  severe  purging  occurs.  Per- 
sonally, I  have  little  faith  in  the  curative  properties  of  any  drug  in  this 
disease.  Plenty  of  fresh  air,  a  good  nutritious  diet,  warm  clothing, 
frequent  bathing  and  rubbing  of  the  skin,  and  a  change  of  residence  at 
intervals  will  assist  Nature  more  than  constant  medication.  It  is  per- 
haps advisable  to  administer  some  of  the  phosphates  when  the  disease 
coexists  with  rickets.  I  have  never  found  the  slightest  beneht  from  the 
use  of  mercurial  inunctions. 

ENCEPHALITIS. 

The  substance  of  the  brain  may  take  on  inflammatory  action  with  or 
without  the  existence  of  a  complicating  meningitis.  It  is  generally  cir- 
cumscribed, although  many  spots  may  be  simultaneously  attected.  The 
latter  is  sometimes  termed  the  "general"  variety.  Sometimes  the  gray 
matter  of  the  cortex  is  alone  involved.  Again,  only  the  medullary  sub- 
stance of  the  brain  may  be  implicated.  Finally,  the  basal  ganglia  (the 
"corpora  striata"  and  "optic  thalami"),  the  cerebellum,  the  medulla 
oblongata,  the  pons  Varolii,  the  crura  cerebri,  and  the  floor  of  the  fourth 
ventricle  have  been  known  to  be  the  seat  of  this  condition. 

Morbid  Anatomy. — The  existence  of  encephalitis  may  be  manifested 
after  death  (1)  as  spots  of  injection  associated  with  abnormal  friability; 
(2)  by  the  presence  of  punctate  extravasations  seen  on  cross-sections  of 
its  substance;  (3)  as  localized  indurations;  (4)  as  red  softening  of  the 
brain-substance ;  (5)  as  circumscribed  collections  of  pus ;  and  (6)  bj' 
gangrene. 

Whenever  cerebral  abscess  has  occurred,  the  cavity  is  usualh* 
encapsulated  by  a  new  connective-tissue  formation. 

Rindfleisch  divides  tlie  stages  of  cerebral  abscess  as  follow :  1.  A 
stage  of  hyperemia ;  2.  The  development  of  infarction  (page  230);  3. 
(Edema  or  hemorrhagic  extravasation ;  4.  Proliferation  of  the  cell  ele- 
ments;  5.  Hypertroph}'  and  induration  (in  chronic  cases);  6.  Softening 
of  the  brain-substance ;  7.  Suppuration ;  8.  A  condition  of  fojtid  suppu- 
ration, resembling  gangrene,  which  is  occasionally  preceded  by  the  devel- 
opment of  a  false  membrane;  9.  Atrophy,  as  a  late  result  of  the  inflam- 
matory changes. 

Etiology. — Among  the  causes  of  encephalitis  which  tend  to  induce 
suppuration  may  be  mentioned  pyjemic  infarction,  direct  injury  to  the 
head,  disease  of  the  internal  ear  or  temporal  bone,  diseases  of  the  nasal 
cavity,  syphilitic  disease  of  the  1>ones  of  the  cranium,  diseases  of  the 
orbit,  cancer,  and  certain  idiopathic  causes  which  are  not  well  under- 
stood. 


CEREBRAL   SOFTENING.  317 

Symptoms. — Encephalitis  is  so  closely  allied  to  red  cerebral  soften 
ing  that  it  will  be  further  discussed  under  that  heading.  The  symptoms 
of  the  disease  must  of  necessity  vary  with  the  seat  and  extent  of  the 
lesion.  Hence  it  is  difficult  to  interpret  them  correctly  unless  the  func- 
tions and  anatomy  of  tlie  various  component  parts  of  the  brain  are  well 
understood.  Pages  (58  to  102  will  aid  the  reader  in  mastering  cerebral 
localization. 

Differential  Diagnosis. — The  points  of  value  in  the  discrimination 
of  this  disease  will  be  given  in  those  pages  which  treat  of  the  diagnosis 
of  cerebral  softening. 

CEREBRAL   SOFTENING. 

The  three  forms  of  this  condition  which  are  recognized  by  most 
authorities  are  the  white,  yellow,  and  red. 

Morbid  Anatomy. — The  pathologj'  of  softening  of  the  brain  may  thus 
be  summarized  : — 

The  white  variety  is  a  chronic  conditicm  in  the  great  majority  of 
cases,  and  is  usually  dependent  upon  some  disease  of  the  small  arteries 
and  capillaries  which  gradually  deprives  the  parts  of  their  normal  nutri- 
tion. There  is  no  hyperemia.  The  parts  are  usuall}'  of  an  opaque  dirty 
white. 

White  softening  may  sometimes  be  acute  ;  in  which  case  it  is  due  to 
a  sudden  ol)struction  of  some  artery  of  large  size  by  an  embolus  or  a 
thrombus. 

The  yellow  variety  is  simply  an  altered  state  of  either  the  white  or 
the  red.  Its  color  is  due  either  to  the  presence  of  altered  blood-pigments 
which  have  arisen  from  a  previous  slight  extravasation ;  or  to  a  fine  state 
of  division  and  a  close  aggregation  of  particles  of  fat  formed  within  a 
mass  of  the  former  varietj'. 

The  red  variety  is  commonly  an  acute  aftection.  As  has  been  stated, 
it  follows  vascular  occlusion  from  an  embolus  or  thrombus ;  or  it  may  be 
the  result  of  an  attack  of  encephalitis.  A  marked  extravasation  of  blood 
into  a  mass  of  white  softening  may  cause  a  red  appearance  to  the  mass, 
but  the  microscopical  appearances  will  differ  from  that  of  the  acute  form 
now  under  consideration.  In  the  red  variety,  there  is  intense  hyperaemia 
from  the  onset,  followed  by  a  rupture  of  the  capillaries  and  an  extravasa- 
tion of  blood.  Its  pathology'  is  similar  to  that  of  "  infarction  "  elsewhere 
in  the  body  (page  229). 

All  forms  of  cerebral  softening  are  liable  to  be  accompanied  by 
disturbances  of  motion  or  sensation,  aphasia,  and  mental  impairment. 
The  seat  and  extent  of  the  lesion  will  govern  the  type  of  its  external 
manifestations.  The  history  of  the  patient  will  often  be  indispensable 
in  deciding  as  to  the  existence  of  softening,  if  in  the  anterior  part  of  the 


318 


LECTURES   ON   NERVOUS   DISEASES. 


frontal,  the  occipital,  or  the  temporal  lobes,  where  the  so-called  "  motor 
centres"  of  the  brain  are  wanting.     (See  Fig.  5.) 

There  is  more  or  less  oedema  into  the  brain-substance  which  sur- 
rounds a  spot  of  red  softening.  This  often  causes  the  area  of  softening 
to  appear  as  an  elevation  abine  the  plane  of  the  section  when  the  brain- 
tissue  is  divided  with  the  knife.  In  cases  where  the  focus  of  softening 
is  of  the  white  or  yellow  variety  tliis  elevation  is  wanting. 

The  debris  which  constitutes  a  focus  of  cerebral  softening  will  be 
found  to  consist  of  fat  granules,  altered  blood-corpuscles,  pigment 
masses,  pus-cells,  disintegrated  nerve-tissue,  caseous  matter,  and  large 
spherical  cells,  filled  with  fat  granules  (Gluge's  corpuscles).  Each 
variety  of  softening  causes  variations  in  the  relative  proportions  of  these 
elements.     The    red    variety    will    exhibit   a   large  admixture   of   blood- 


FiG.  So  — Softened  Brain-Tissue      (After  Fox  ) 

corpuscles,  pigment  granules,  and  Gluge's  cells;  the  yellow  and  white 
varieties  will  be  accompanied  b}"  an  excess  of  fatty  matter  or  caseous 
substance,  and  a  small  admixture  of  altered  blood  pigments,  corpora 
amylacea,  and  crystals. 

Etiology. — It  is  a  mistake  to  suppose  that  cerebral  softening  occurs 
only  in  the  aged.  Old  age  is  indeed  a  preeminent  factor  in  exciting  cere- 
bral thrombosis ;  and  that  condition  is  followed,  as  a  rule,  b}"  softening  of 
the  brain  in  the  old.  Still,  the  more  common  exciting  causes  of  this  dis- 
ease include  (in  addition  to  cerebral  enil)olisin  and  thrombosis)  pyjemia, 
syphilis,  alcoholism,  sun-stroke,  and  cereln-al  hemorrhage,  all  of  which 
may  exist  independently  of  old  age.  I  have  to-day  under  my  care  a 
young  married  lady  (thirty  years  old)  who  has  marked  cerebral  soften- 
ing that  was  indnct'd  Ijy  an  embolic  attack  during  the  puerperal  state,  in- 
de[)eiidentlv   of  any   lesion   of  the  valves  of  the  heart.     Another  of  my 


CEREBKAL   SOFTENING.  319 

patients  developed  cerebral  softening  as  a  result  of  gumuuitous  pachy- 
meningitis when  but  thirty-five  years  of  age.  All  the  exciting  causes 
of  abscess  of  the  brain  may  occasion  cerebral  softening  under  favorable 
circumstances.  Among  these  may  be  mentioned  the  exanthematous 
fevers,  glanders,  the  puerperal  state,  mercurial-  and  lead-poisoning,  ne- 
crosis, osteo-myelitis,  pyaemia  and  septictemia,  abscess  of  the  viscera, 
and  many  others. 

The  white  variety  results  from  causes  that  tend  to  so  impair  the 
blood-supply  of  the  softened  part  as  to  deprive  it  of  nutrition  without 
creating  at  the  same  time  a  hemorrhage  from  the  surrounding  capillaries. 
It  is  often  designated  as  the  ''  non-inflammatory  form,"  in  contrast  to  the 
red,  which  is  commonly  of  inflammatory  origin. 

The  nature  and  mode  of  suppression  of  the  blood-supply  to  portions 
of  the  brain,  more  or  less  limited,  governs  to  a  great  extent  the  variety  of 
softening  which  results.  As  has  been  stated  in  a  previous  page,  the  ar- 
teries, capillaries,  or  sinuses  of  the  brain  may  be  independently  occluded. 
Thrombosis  or  embolism  may  be  the  immediate  cause  of  such  occlusion, 
or  the  blood-supply  may  be  arrested  by  pressure  upon  the  vessels  by  new 
growths  within  the  skull,  or  from  without,  as  in  the  case  of  hemorrhage, 
tumors,  ligation,  o3dematous  inflltration,  etc. 

The  rapidity  of  arrest  of  the  circulation,  and  the  extent  of  collateral 
fluxion  which  immediately  follows  (within  twenty-four  or  forty-eight 
hours),  are  the  factors  which  govern  the  results  which  follow.  The  col- 
lateral circulation  may  be  sufficient  in  some  cases  to  arrest  the  immediate 
death  of  the  parts  suddenly  deprived  of  blood  by  an  embolus  or  thrombus, 
or  some  quickly-developed  and  extreme  pressure  upon  the  blood-vessels. 
Again,  it  may  be  so  great  as  to  cause  a  capillary  hemorrhage,  giving  the 
softened  area  a  red  appearance  (infarction)  immediatel}-  after  the  arrest 
of  its  normal  blood-supply.  Finally,  inflammatory  action,  as  in  true 
encephalitis,  may  create  the  red  variety  of  softening. 

Symptoms. — It  is  not  always  possible  to  make  a  positive  diagnosis 
of  cerebral  softening.  The  symptoms  may  be  influenced  to  a  greater 
or  less  extent  (1)  by  the  exciting  cause;  (2)  by  the  seat  of  the  focus  of 
softening;  (3)  by  the  variety  of  softening  which  exists;  (4)  by  the  de- 
velopment of  suppuration  ;  and  (5)  by  the  occurrence  of  hemorrhagic 
extravasation  into  the  softened  brain-tissue. 

Notwithstanding  these  elements  of  uncertainty  in  diagnosis,  it  is 
generally  possible  to  arrive  at  some  definite  conclusions  by  a  careful 
study  of  each  case  and  the  exclusion  of  the  other  conditions  of  the  brain 
whose  symptoms  closely  resemble  those  of  softening. 

Encephalitis  or  infiammatory  red  softening  is  accompanied,  as  a  rule, 
by  febrile  symptoms  of  a  marked  kind.  The  temperature  often  rises  to 
103°  F.,  and  the  pulse  becomes  more  or  less  accelerated  at  first.     Later 


3'iO  LECTURES   ON    NERVOTTS   DISEASES. 

in  the  disease,  tlu'  pulse  iiiiiy  1»<'  slower-  than  nornuil.  Headache  is  a 
marked  symptom.  It  is  often  accompanied  by  vertigo,  sonmolence. 
hypenesthesia,  formication,  i)riiritus,  neuralgic  pains,  vomiting,  and  con- 
fusion of  intellect.  Later,  it  may  he  attended  with  delirium,  muscular 
twitchings,  general  convulsions,  a  tottering  gait,  imperfections  of  speech, 
motor  or  sensory  paralysis,  and  connx.  Amnesic  or  ataxic  apliasia  may 
be  deveh:)i)ed.  The  face  frequently  becomes  flushed,  :ind  an  irregularity 
of  the  pupils  m:iy  be  occasionally  observed. 

When  an  apoplectic  extravasation  occurs  into  the  softened  mass,  pro- 
found coma  and  i)aralysis  suddenly  appear.  Other  evidences  of  cerebral 
disturbance  may  also  exist.  Hemiana'sthesia  will  generally  coexist  with 
hemiplegia,  the  functions  of  sensation  and  motion  being  aflected  upon  the 
same  side,  if  the  disease  is  confined  to  one  cerebral  hemisphere.  When 
the  hemorrhage  is  extensive,  death  occurs  within  forty -eight  hours.  In 
instances  of  a  less  severe  type  life  is  not  destroj-ed,  but  the  recovery  of 
motility  and  sensibility  is  seldom  complete. 

The  ophthalmoscope  may  often  prove  of  service  in  the  diagnosis  of 
cerebral  softening.  It  enables  the  physician  to  detect  changes  in  the  size 
and  course  of  the  retinal  vessels. 

Cerebral  softening  of  the  non-infiummatoni  variety  may  he  due  to  an 
attack  of  embolism  or  thrombosis,  or  to  mechanical  compression  of  some 
of  the  cerebral  arteries  or  sinuses.  The  method  of  onset  will  be  modified, 
therefore,  by  the  exciting  cause.  The  symptoms  of  each  of  the  causes 
enumerated  have  been  given  in  preceding  pages. 

When  aged  subjects  are  attacked  by  cerebral  softening,  the  history 
of  the  case  is  often  extremely  vague  and  unsatisfactory.  Many  instances 
have  been  recorded  in  w^hich  extensive  foci  of  softening,  abscesses  of  large 
size,  and  direct  injuries  to  the  ])rain  have  not  been  suspected  during  life, 
although  they  were  encountered  at  the  autopsy.  We  are  justified  in 
attributing  diagnostic  value,  therefore,  to  certain  symptoms  when  taken 
collective!}',  which  would  be  of  little  importance  alone.  Thus,  for  ex- 
ample, when  an  aged  person  begins  to  exhibit  an  impairment  of  memory, 
unnatural  peevishness  and  irritability,  an  imperfect  control  over  the 
emotions,  despondency,  an  incapacity  for  prolonged  mental  effort, 
physical  weakness,  a  diminution  of  motor  power  in  the  legs  or  arms,  a 
monotonous  habit  (^f  speech  or  gesture,  etc.,  we  are  forced  to  the 
conclusion  that  they  indicate  collectively  some  serious  form  of  disease. 
We  are  strengthened  in  this  conclusion  if  these  symptoms  are  followed 
after  a  lapse  of  time  b}^  an  awkwardness  of  movement,  a,  tottering  gait, 
dementia,  or  the  sudden  development  of  paralysis  of  sensibility  or 
motility. 

Cases  of  cerebral  softening  frequently  develop  a  peculiar  tendency  to 
clip  otf  words  during  attempts  at  conversation  or  reading.     These  cases 


CEKEBRAL   SOFTENING.  321 

exhibit  also  an  iiiabilitv  to  iimiiitain  coiitimious  muscular  contraction, 
an  excitability  when  questioned  concernino;  their  ailments,  a  lack  of 
regard  for  personal  cleanliness  and  the  decencies  of  life,  groundless 
prejudices,  and  manj'  other  evidences  of  mental  decay. 

Paralysis  of  motion  may  develop  gradually  (as  well  as  suddenly)  in 
connection  with  cerebral  softening.  In  such  a  case  the  impairment  of 
motility  will  general^  be  perceived  in  the  lingers  or  toes  first,  and 
steadily  advance  toward  the  trunk.  This  method  of  attack  is  called 
"  creeping  palsy,"  in  contradistinction  from  paralysis  of  sudden  advent. 

When  cerebral  softening  is  far  advanced,  it  is  not  uncommon  to  en- 
counter bed-sores  upon  the  nates.  They  resist  all  methods  ol'  treatment, 
and  indicate  "  trophic  disturbances  "'  of  the  skin. 

Respecting  the  seat  of  softening,  some  deductions  can  occasionally 
be  drawn  during  life  from  the  symptoms  presented. 

When  deglutition  becomes  difficult,  or  when  the  respirator}^  or  cir- 
culatory functions  are  markedly  affected,  we  are  justified  in  suspecting 
that  the  basilar  artery  has  probably  been  occluded,  and  that  softening 
of  the  pons  or  medulla  exists. 

The  ocular  muscles  may  be  rendered  })aretic  by  a  focus  of  softening 
in  the  cerebri  cms. 

If  the  temporal  lobes  of  the  (•ere})rum  are  attacked,  we  may  meet  with 
disturbances  of  hearing,  smell,  and  taste.  Word-deafness  may  also  be 
encountered,  es})ecially  if  the  left  hemisphere  is  involved. 

Softening  of  the  occipital  lobes  may  give  rise  to  visual  disturbances, 
snch  as  colored  spectra,  hemianopsia,  a  loss  of  the  memory  of  past  sight- 
perceptions,  word-blindness,  etc. 

Evidences  of  impairment  of  motility  are  liable  to  be  developed  early 
when  the  motor  area  of  the  corte.r.  or  that  part  of  the  centrum  ovale 
through  which  the  motor  fibres  pass  to  the  internal  capsule  (fig.  6)  are 
attacked. 

Lesions  of  the  centrum  ovale  may  be  diagnosed  in  some  cases  by 
tests  mentioned  on  page  184. 

The  cerebral  cortex,  the  basal  ganglia  (corj)us  striatum  and  optic 
thalamus  of  each  cerebral  hemisphere),  and  the  Avhite  substance  of  the 
cerebrum  are  most  frequently  attacked.  The  area  of  softening  seldom 
crosses  the  mesial  line. 

The  causes  of  death  in  this  disease  arc  various.  Some  patients  die 
of  slow  exhaustion  Others  develop  asph^^xia,  on  account  of  a  disturb- 
ance of  respiration.  Not  infrequently  convulsions  produce  death  by 
interfering  with  respiration.  Instances  have  been  recorded  where  a 
patient  has  been  choked  to  death  during  an  attempt  to  swallow,  or  from 
regurgitation  of  food  when  in  a  convulsion.  Finalh\  deep  coma  may 
develop  before  death. 


322 


LECTURES    ON    NERVOUS   DISEASES. 


Differential  Diagnosis. — 'VUv  intlaniiiuitoiv  variety  may  be  mistaken 
for  acute  meningitis.  The  non-intlainmatory  varieties  sometimes  re- 
semble, in  tlieir  symptomatology,  the  conditions  of  cerebral  tumor, 
cerebral  abscess,  chronic  meningitis,  and  hiematoma  of  the  dura. 

Acute  meni/ujitis  is  accompaniecl  by  a  iiigher  range  of  temperature 
than  red  softening.  Its  stages  are  distinctly  marked.  It  has  a  com- 
paratively short  duration.  Headache  is  intense  at  the  onset.  Vomiting 
is  a  prominent  symptom.     The  pulse  is  also  characteristic. 

Cerebral  tumors  do  not,  as  a  rule,  cause  as  much  embarrassment  of 
speech  or  impairment  of  intellect  as  softening,  because  they  afl'ect  the 
frontal  lobes  less  frequently  than  some  other  regions.  They  are  accom- 
panied, in  a  large  proportion  of  cases,  by  a  pnin  in  the  head  that  is  more 


Fig.  86. — The  Fundus  op  the  Normal  Eye. —  The 
reader  should  compare  this  cut  with  the  ne.xt  one 
in  order  to  appreciate  the  appearance  of  the  so- 
called  "  choked  disk." 


Vic.  vS7. — The  Apfe.-\r.\nce  of  the  Fundus  of 
THE  Eye  when  an  Excess  of  Intra-Cranial 
Pressure  has  caused  a  Neuro-Retinitis, 
resulting  in  the  condition  known  as 
"Choked  Disk." 


localized  than  wiien  due  to  softening  of  the  brain.  The  cranial  nerves 
are  liable  to  be  implit^ated  early.  Monoplegia  or  monospasm  is  not  an 
infrequent  symi>tom  of  tumor  near  the  motor  centres.  Convulsions  are 
more  frequently  observed  in  connection  with  tumors  than  with  soft- 
ening, and  are  of  the  epileptiform  type.  A  history  of  syphilitic  infection 
is  often  present,  since  many  cerebral  tumors  are  of  the  gummatous 
variety.  Choked  disk  is  generally  detected  when  cerebral  tumor  is 
present.  The  thermo-electric  difterential  calorimeter  (Fig.  71)  will  often 
show  a  marked  variation  in  the  temperature  of  the  scalp  over  the  tumor 
from  that  of  surrounding  parts.  This  instrument  is  of  great  value, 
therefore,  in  such  cases. 

Cerebral  abscess  usually  follows  traumatism,  or  an  attack  of  cerebral 
embolism  or  thrombosis.      It  may  be  acc()m])anied  by  a  swelling  of  the 


CEREBRAL   SOFTENING.  323 

scalp,  the  so-called  "Pott's  puffy  tumor."  It  sometimes  occurs  in 
connection  with  pyiemia.  Occasionally  it  follows  an  attack  of  cerebral 
hemorrhage  or  cerebritis.  Rigors  may  be  present  when  the  abscess  is 
forming,  and  more  or  less  febrile  disturbance  will  generally  exist. 

Chronic  meningitis  so  closely  resembles  cerebral  softening  in  some 
cases  that  the  differential  diagnosis  is  impossible.  As  a  rule,  however, 
the  headache  of  chronic  meningitis  is  more  diff"used  than  in  softening. 
The  intellectual  foculties  and  speech  are  not  as  progressively  embarrassed: 
Spasms  of  the  limbs  are  frequently  developed.  The  impairment  of 
motility  in  the  limbs  is  not  as  dirt"used  as  in  softening. 

Pachymeningitis  interna  (haimatoma  of  the  dura)  may  be  confounded 
with  cerebral  softening.  The  history  of  the  patient  will  generally  suffice 
to  clear  up  existing  doubts.  (See  previous  pages,  which  treat  of  this 
condition.) 

The  following  table  *  will  possibly  aid  the  reader  still  further  in 
making  the  discrimination  between  cerebral  softening  and  cerebral 
tumor  : — 

CEREBRAL   TUMORS.  CEREBRAL  SOFTENING. 

Headache. 
Headache  usually  exists  in  the  frontal  or  Headache  is  less  severe,  and  usually  con- 

temporal  region ;  occasionally  in  the  occi-       fined  to  the  frontal  region, 
pital   region.     It  is  either  intermittent  or  Paroxysms  of  pain  in  the  head  are  less 

paroxysmal  at  first;  but  it  tends  to  become  frequent.  It  is  more  commonly  continuous, 
continuous  and  rebellious  to  treatment.  It 
is  not  necessarily  over  the  seat  of  the  tumor. 
This  symptom  is  most  marked  in  those 
cases  where  the  meninges  are  subjected  to 
tension  by  the  growth  of  the  tumor. 

Vertigo. 

Vertigo  is  quite  a  frequent  symptom  in  Vertigo  is  not  specially  characteristic  of 

connection  with  the  headache.     If  the  tu-       cerebral  softening, 
mor  is  near  the  temporal  region,  the  vertigo 
is  apt  tv^  be  especially  severe.    The  same  de- 
duction applies  to  tumors  of  the  cerebellum. 

Early  Effects  of  Lesion. 

Disturbances  in  both  sensation  and  mo-  The  mental  faculties  exhibit  impairment 

tion  are  apt  to  be  developed  when  the  cor-  early. 

tex  is  subjected  to  irritation  or  is  pressed  Later  in  the  disease  the  body  may  be  sud- 

upon  by  the  tumor.  denly  rendered   hemiplegia  or  the  patient 

Monoplegia,    monospasm,    monoannssthe-  may  become  aphasic. 
sia,  monoparffisthesise,  aphasia,  etc.,  may  be 
encountered. 

*  This  table  is  modified  from  one  originally  published  in  the  Author's   work  on 
"Surgical  Diagnosis,"  3d  uditiou. 


324 


LECTURES   ON   NERVOUS   DISEASES. 


Sensory  Phknomena. 


Late  sensory  disturbances  which  may  de- 
velop include  neuralgic  attacks;  numbness; 
formication  ;  reflex  cramps,  etc.  These  may 
be  followed  by  more  or  less  general  anaes- 
thesia, abolition  of  the  muscular  sense,  etc. 


Sensory  symptoms,  when  present,  are  not 
as  marked  as  in  tumors.  In  some  situations, 
cerebral  softening  does  not  induce  them. 


Motor  Phenomena. 


The  motor  phenomena  which  may  be 
induced  comprise  a  stiffness  of  the  muscles 
a  relaxed  condition  of  one  member  or  limb 
spasms  of  the  tonic  or  clonic  type ;  tremor 
permanent  contraction  of  muscles ;  paresis 
monoplegia  ;  hemiplegia ;  paraplegia ;  uni- 
lateral ataxia,  etc. 

Crossed  paralysis  in  any  of  its  more  com- 
mon forms  may  occur. 

Double  or  alternate  paralysis,  when  pres- 
ent, is  especially  characteristic  of  tumors. 


Hemiplegia  (which  is  usually  of  sudden 
origin  and  complex)  is  more  common  than  in 
tumors. 

Aphasia  is  often  developed  with  the  hem- 
iplegia. 


Double  or  alternate  paralysis  is  rare. 


Special  Senses. 


Choked  disk,  anosmia,  amblyopia,  amau- 
rosis, auditory  disturbances,  and  loss  of  taste 
have  all  been  observed  to  follow  the  devel- 
opment of  cerebral  tumors. 


Disorders  of  the  special  senses  are  less  fre- 
quent than  in  tumors ;  when  present,  they 
do  not  tend  to  progressively  involve  one 
special  sense  after  another. 


Speech 


Is  infrequently  affected  by  motor  or  sen- 
sory aphasia.  The  speech  is  often  embar- 
rassed, however,  by  sputtering,  imperfect 
utterance,  etc. 

Mental  Faculties 
Impaired  late,  if  at  all.  Impaired  early 


Is  frequently  affected.    "When  so,  the  con- 
dition of  aphasia  is  commonlj'  present. 


Etiology. 


Tuberculosis,  cancerous  cachexia,  syph- 
ilis, and  diseases  which  induce  changes  in 
the  cranial  bones,  are  frequent  causes  of 
tumors  within  the  skull. 


Frequently  follows  disease  of  the  tem- 
poral bone ;  if  so,  it  is  preceded  by  aural 
disturbances. 

Embolism,  cerebral  thrombosis,  and  apo- 
plexy, are  frequent  causes  of  cerebral  soft- 
ening. 


Symptoms  in  Common. 

Both  may  be  associated  with  headache. 

"  "  "      impairment  of  mental  faculties. 

"  "  "  "  "  motion. 

"  "  "  "  "  sensation. 

"  "  "  "  speech. 

"  "  "  "  "  special  senses. 


CEEEBKAL   SOFTENING.  325 

Prognosis. — The  duration  of  life  depends  upon  the  cause,  extent, 
and  variety  of  softening.  While  it  may  be  said  that  death  usually  results 
from  cerebral  softening  sooner  or  later,  I  believe  that  recovery  may  occur. 
Many  of  the  reported  cases  of  cure  are  undoubtedly  those  of  error  in 
diagnosis ;  but  small  foci  of  softening  ma}^  to  my  mind,  become  encap- 
sulated in  young  and  healthy  subjects,  and  do  no  more  harm  than 
extravasations  of  a  limited  extent. 

Red  softening  is  liable  to  lead  to  cerebral  abscess.  It  frequentl}^ 
destroys  life  within  two  weeks.  The  non-inflammatory  varieties  may 
cause  progressive  symptoms  for  years.  When  death  occurs  in  these 
cases,  it  is  usually  the  result  of  some  complication,  such  as  those  of  the 
lung,  meningitis,  apoplexy,  diarrhoea,  interference  with  the  centres  of  the 
medulla,  bed-sores,  anaemia,  etc. 

Treatment. — The  fact  that  instances  of  apparent  cure  of  this  affec- 
tion are  occasionally  reported  (two  of  which  I  have  personall}'^  observed) 
should  justify  us  in  not  discarding  all  remedial  measures. 

The  treatment  of  each  individual  case  will  be  modified  somewhat 
by  the  history  of  the  patient.  If  the  sj'mptoms  of  cerebral  softening- 
follow  an  attack  of  cerebral  embolism  or  thrombosis,  the  suggestions 
previously  offered  regarding  the  treatment  of  those  conditions  will 
be  indicated.  If  it  be  due  to  some  form  of  tumor,  or  the  pressure  of 
inflammatory  exudation,  efforts  should  be  made  to  create  absorption  and 
to  arrest  its  development.  (See  treatment  of  meningitis  and  tumors.) 
When  cerebral  softening  follows  an}-  of  the  varieties  of  blood-poisoning 
enumerated  in  previous  pages,  the  indications  for  treatment  are  to  aid 
nutrition  b}^  all  possible  means,  and  to  S3stematicall3'  promote  physical 
vigor.  In  young  and  previously  vigorous  subjects,  this  can  be  done 
more  satisfactorily  than  in  aged  or  enfeebled  constitutions. 

The  treatment  of  the  acute  variety  should  differ  from  that  of  the 
chronic  form,  since  enforced  confinement  to  bed,  mental  quietude,  cold  to 
the  head,  the  internal  administration  of  stimulants  in  some  cases,  and  the 
employment  of  heat  to  the  extremities  are  frequently  indicated  in  tlie 
former. 

When  the  disease  is  inclined  toward  chronicity  the  management  of 
each  case  must  be  modified  by  the  S3'mptoms  presented.  It  is  always 
well  to  guard  against  any  mental  anxiet}'  or  fatigue  of  mind  or  body  ; 
lience  pleasant  surroundings,  cheerful  companionship,  regular  exercise, 
abstinence  from  business,  cessation  from  reading  or  writing,  driving  or 
riding  in  the  open  air,  etc.,  are  important  factors  in  the  treatment.  I 
prefer  the  milk  diet  to  an}-  other  Ibrm  of  administering  nutrition  in  tliose 
cases.  One  of  my  patients  consumed  tliree  quarts  of  milk  daily  for  over 
three  months  without  solid  food,  and  experienced  the  greatest  benetit. 
The  bowels  should  be  carefully  watched.     It  is  my  custom  to  give  from 


326  LECTURES   ON   NERVOUS   DISEASES. 

a  teaspoonful  to  a  tablespoonful  of  uiiuroimd  white  mustard-seed  before 
breakfast  and  at  bed-time  to  patients  who  suffer  from  habitual  constipa- 
tion.    It  acts  charmingly  in  many  cases. 

As  a  tonic  I  often  give  to  these  patients  a  pill  recommended  l)y 
Hammond,  consisting  of  a  half-grain  of  the  extract  of  nux  vomica  and 
one-tenth  grain  of  the  phosphide  of  zinc.  One  of  these  i)ills  should  be 
taken  after  each  meal.  Combinations  of  phosphorus,  iron,  strychnia, 
and  quinine,  are  usually  of  benelit  to  these  subjects.  Cod-liver  oil  is  of 
the  greatest  service  in  some  cases. 

The  insomnia  and  delirium  which  often  accompanies  the  disease  can 
be  overcome  by  the  bromides  of  soda  or  potash  (thirty  grain  dose), 
chloral  (ten  to  twenty  grain  dose),  cannabis  indica  (one-quarter  grain 
dose),  and  by  the  judicious  use  of  alcoholic  stimulants. 

Electricity  forms  a  valuable  adjunct  to  the  other  methods  of  treat- 
ment already  mentioned.  It  is  my  custom  to  use  the  faradaic  current 
daily  upon  the  extremities  when  paralyzed,  and  the  galvanic  current 
(about  fifteen  or  eighteen  cells)  transmitted  from  the  forehead  to  the 
back  of  the  head  for  about  five  minutes  every  other  day,  irrespective  of 
paralysis.  When  the  paralyzed  muscles  begin  to  exhibit  evidences  of 
defective  nutrition,  I  employ  the  galvanic  current  in  place  of  the  faradaic. 

The  emplo^^ment  of  the  actual  cautery  to  the  nape  of  the  neck,  and 
of  croton  oil  to  the  shaven  scalp  has  been  recommended.  I  have  never 
tried  the  latter  because  I  can  see  no  indication  for  its  use.  The  former  I 
have  tried  with  the  most  unsatisfactory  results.  The  experience  of  most 
of  the  prominent  neurologists  seems  to  be  in  accord  witli  m}^  own.  Ham- 
mond states  that  the  speepli  was  rendered  more  embarrassed  and  the  mind 
weaker  than  before  its  application  in  his  experiments  with  it. 

Finally,  the  development  of  bed-sores  should  be  regarded  as  a 
serious  complication.  They  should  be  treated  by  a  fenestrated  air- 
cushion,  or  some  form  of  dressing  that  will  relieve  the  seat  of  ulceration 
from  pressure. 

The  use  of  alcoholic  stimulants  is  indicated  when  the  vital  forces  are 
below  par.  To  aged  subjects  I  frequently  give  a  liberal  supply  of  wine 
with  the  meals.  The  effect  of  stimulation  upon  the  patient  is  the  guide 
to  the  quantity  which  should  be  prescribed  in  each  case. 

CEREBRAL  ABSCESS. 

Suppuration  of  the  brain-substance  may  be  due  to  a  variety  of  causes. 
Cerebral  abscesses  may  be  single  or  multiple,  and  acute  or  chronic. 

Morbid  Anatomy. — Collections  of  pus  within  the  brain  are  most 
frequently  found  in  the  centrum  ovale  of  the  cerebral  hemispheres  and 
next  in  the  cerebellum.  Occasionally  they  are  developed  in  the  substance 
of  the  basal  ganglia,  the  crus,  and  the  pons.     Their  size  varies  from  that 


CEREBEAL   ABSCESS.  327 

of  a  small  walnut  to  a  goose-egg.  A  limiting  membrane  may  or  may  not 
exist. 

The  contents  of  the  abscess  consist  of  a  creamy  fluid,  which  is 
usually  of  a  greenish  hue,  and  inodorous  except  when  pysemic.  It  is 
composed  of  pus  corpuscles,  the  debris  of  broken  down  brain-tissue, 
fatty  matter,  crystals,  and  salts.  The  periphery  of  the  abscess  is  often 
surrounded  by  a  zone  of  yellow  softening  (Rokitansk}-).  Sometimes  a 
well-marked  encapsulation  is  detected,  due  to  a  fibrinous  wall  which  may 
reach  a  quarter  of  an  inch  in  thickness. 

Embolic  abscesses  are  multiple,  as  a  rule.  They  are  usuall}^  of  small 
size. 

Abscesses  of  the  brain  sometimes  rupture  into  the  ventricles — more 
rarely  into  the  tympanum,  the  nostril,  or  the  cavity  of  the  orbit.  They 
often  create  a  complicating  meningitis  by  pointing  toward  the  convexity 
of  the  cerebral  hemispheres.  After  an  extensive  meningitis,  the  pus  has 
been  known  to  perforate  the  calvaria. 

The  reaction  of  the  fluid  contents  may  be  alkaline  or  acid.  If 
mucine  be  present,  the  pus  ma}'  appear  gelatinous  and  ropy.  If  the 
process  of  absorption  takes  place  the  contents  of  the  cavity  may  disap- 
pear, and  be  followed  b}"  a  retraction  of  the  wall  of  the  cyst  and  the 
formation  of  calcareous  deposits  or  of  cheesy  masses. 

The  pressure  created  b}'  the  accumulation  of  pus  tends  to  distort 
and  flatten  neighboring  convolutions,  and  to  interfere  more  or  less  with 
their  nutrition. 

Etiology. — Among  the  most  freqnent  causes  of  cerebral  abscess  the 
following  may  be  mentioned :  Sup[)uration  of  the  middle  ear ;  blows  re- 
ceived upon  the  convexity  of  the  skull;  erysipelas  of  the  face  or  scalp; 
suppuration  of  the  orbit  or  nasal  fossa ;  caries  or  necrosis  of  the  skull ; 
cerebritis  ;  embolism  ;  pyaemia  ;  glanders  ;  some  of  the  eruptive  fevers  ; 
and  other  blood-poisons. 

Symptoms. — These  will  be  modified  (1)  b}-  the  seat  and  extent  of  the 
abscess  ;  (2)  by  the  causes  which  induced  it;  and  (3)  by  the  complications 
which  are  developed.  The  presence  of  rigors,  with  parox^-sras  of  fever 
at  irregular  intervals,  should  lead  us  to  suspect  suppuration  when  in 
doubt.  The  fact  that  abscess  has  been  known  to  exist  for  many  months 
in  some  parts  of  the  cerebrum  without  inducing  any  symptoms,  should 
be  remembered  by  those  who  are  inclined  to  be  hasty  in  their  clinical 
deductions.  I  would  again  impress  upon  the  mind  of  the  reader  in  this 
connection  the  necessity  of  a  familiarity  with  the  deductions  embodied 
in  the  first  two  sections  of  this  work,  as  a  basis  for  all  clinical  deductions 
respecting  the  localization  of  cerebral  lesions  during  life. 

Differential  Diagnosis. — The  symptoms  of  cerebral  abscess  are  apt 
to  be  confounded  with  those  of  cerebral  tumor  and  softening. 


328  LECTUEES  ON  NERVOUS  DISEASES. 

From  cerebral  tumor,  the  rapid  emaciation  and  short  duration  of 
life,  the  presence  of  rigors  and  paroxysms  of  fever,  the  iiistory  of  the 
case,  the  infrecjuency  of  paralysis  of  special  cranial  nerves,  and  the  pos- 
sible escape  of  pus  from  the  ear,  nose,  or  orbit,  would  make  the  diag- 
nosis of  abscess  possible  in  many  cases. 

From  cerebral  softening  the  presence  of  intra-cranial  pain,  rigors, 
and  paroxysms  of  fever,  a  healthy  state  of  the  superficial  blood-vessels, 
and  other  symptoms  mentioned  above  would  point  toward  the  diagnosis 
of  abscess. 

The  table  on  the  opposite  page  may  prove  of  assistance  to  the  reader 
in  making  a  diagnosis. 

Prognosis. — If  suppuration  occur  in  connection  with  acute  enceph- 
alitis, death  may  follow  rapidly  (from  three  days  to  three  weeks). 

Chronic  abscess  of  the  brain  may  exist  for  years.  If  it  excites  com- 
plications of  a  serious  kind,  such  as  diti'use  meningitis,  thrombosis  of  the 
sinuses,  oedema,  extensive  softening,  effusion  into  the  ventricles,  pressure 
upon  vital  centres,  pulmonar^^  congestion,  etc.,  death  may  be  indirectly 
produced  by  it. 

Treatment. — Trephining  for  well-defined  collections  of  pus  within  or 
upon  the  brain  has  lately  assumed  a  prominent  place  among  the  modern 
surgical  procedures.  The  recent  discoveries  made  respecting  the  cortical 
centres  of  the  cerebrum  enable  us  to  interpret  the  clinical  evidences  of 
circumscribed  pressure  upon  distinct  areas  of  the  brain,  and  to  talie 
steps  for  their  relief  which  were  not  dreamed  of  until  within  the  last 
decade.  It  is  hoped  that  the  first  two  sections  of  this  work  will  aid  the 
reader  to  take  such  a  step  when  necessary  with  confidence  and  judg- 
ment. 

SCLEROSIS   OF   THE   BRAIN. 

The  term  "  sclerosis  "  is  used  to  designate  a  condition  characterized 
by  an  increase  in  the  connective  tissue  of  an  organ. 

This  newly-formed  connective  tissue  subsequently  contracts,  and 
induces  atrophy  of  those  parts  which  are  thus  subjected  to  pressure, 
because  the  blood-supply  is  gradually  diminished. 

Morbid  Anatomy. — In  the  nerve-centres,  this  condition  may  assume 
different  forms  :  1.  It  may  constitute  the  so-called  "general  "  or  "diffuse 
sclerosis;"  seldom  involving  the  brain,  but  not  infrequently  affecting 
large  tracts  of  the  spinal  cord.  2.  It  may  be  disseminated  throughout 
the  brain  and  spinal  cord,  constituting  the  "  sclerose  en  plnques"  of  the 
French  authors,  or  "multiple  sclerosis"  of  English  and  American 
writers  3.  A  variety  of  the  second  form,  termed  "  miliary  sclerosis," 
has  also  been  described. 

Sclerosis  of  the  brain  probably  starts  as  a  chronic  congestion,  which 


CEREBRAL   ABSCESS. 


329 


DIAGNOSTIC  SYMPTOMS. 


Headache 


Vertigo 


Mental  Impairment. 


in  cerebral 
softening. 


'  Usually  frontal. 
Generally  con- 
tinuous. May  be 
absent  through- 
out the  disease. 


May  be  absent. 


'Apt     to    be    a 
marked  symp- 
tom. 
Develops     gradu- 
ally (as  a  rule). 


IN   CEREBRAL  TUMOR. 


Sensory  Phenomena    .  j  May  be  normal. 


Motor  Phenomena 

Special  Senses  .   . 

Rigors    

Emaciation    .    .    . 


Course  of  the  Disease. 
Temperature    .    .    .    . 

Clinical  History    .    . 
Speech    


Paralysis  of  mo- 
tion may  occur 
suddenly  or  pro- 
gre.«sively.  It  is 
sometimes  not 
developed. 


May  be  normal. 


Seldom  observed. 

(  Progressive  or 
(     viranting. 

Chronic. 
Normal. 


Cause  may  be  ob- 
scure. 

Is   apt  to  be  im- 
paired. 


'  Seat  variable,  but 
pain  is  seldom 
absent.  Is  most 
severe  when  the 
cerebellum  is  dis- 
eased. Is  apt  to 
exhibit  distinct 
paroxysms.  Is 
caused  by  ten- 
sion of  the  me- 
ninges. 

'  Is  particularly  apt 
to  occur  when  the 
cerebellum  or 
temporal  lobe  is 
affected. 


in  cerebral 

abscess. 


Often  absent. 


The  sensor}^  con- 
ducting tracts  are 
sometimes  very 
markedly  dis- 
turbed. 


Motility  is  not  in- 
frequently affect- 
ed by  the  growth 
of  the  lesion. 


'  Liable  to  be  pro- 
gressively affect- 
ed. "Choked 
disk  "  is  pathog- 
nomonic. 

Generally  absent. 

Progressive    or    ab- 
sent. 

Usually  chronic. 

Usually  normal. 

!If  non-syphilitic, 
the  history  will 
be  of  a  negative 
kind. 

>  Usually  normal. 


May  be  absent,  but 
is  usually  very 
well  marked  and 
localized. 


May  be  absent. 


Develops 
if  at  all. 


rapidly 


'  If  sensation  is  dis- 
turbed, anassthe- 
sia  of  a  unilateral 
type  may  be  de- 
tected. 
Sensation  may  be 
unaffected. 


Paralysis  of  mo- 
,  tion  may  or  may 
I     not  be  developed. 

'  May  escape  im- 
pairment if  the 
abscess  be  of 
moderate  size 
and  circum- 
scribed. 
i  A  strong  diagnos- 
(     lie  symjitom. 

>  Rapid,  as  a  rule. 

(  Rapidly  fatal,  as  a 

}     rule. 

(  Markedly    ele- 

(     vated. 

The  history  will 
usually  point  to 
an  exciting  cause 
of  the  symptoms. 

May  be  impaired. 


330  LECTURES    ON   NERVOUS   DISEASES. 

leads  to  an  exudation  of  an  albuminous  fluid,  and  subsequently  to  cell- 
proliferation  in  the  neuroglia. 

It  is  closely  allied  to  inflammatory  processes,  if  not  strictly  de- 
pendent upon  them. 

Injuries  to  the  convolutions  of  the  so-called  "motor  area,"  or  a 
severance  of  the  ''  motor  tracts  "  of  the  brain  (complete  or  partial) 
seem  to  act  as  an  exciting  cause  of  a  so-called  "descending  scle- 
rosis "  which  confines  itself  to  the  tract  of  fibres  that  are  functionally 
associated  with  the  parts  injured.  In  this  way  it  eventually  reaches  the 
spinal  cord.  Similar  changes  ma^'  involve  the  cranial  nerves,  chiefly  the 
optic. 

In  chronic  insanit}',  sclerosis  of  the  brain  is  not  infrequently  de- 
tected ;  and  the  same  may  be  said  of  general  paralysis,  some  cases  of 
epileps}',  Duchenne's  malady,  paresis,  paralytic  tremor,  and  idiocy. 

The  diffused  or  general  variety  is  described  by  some  authors  under 
the  term  '■'■induration  of  the  brain.''^  This  is  because  an  abnormal  hard- 
ness of  the  cerebral  tissue  can  be  detected,  and  the  brain  cuts  with 
greater  resistance  than  when  health}'. 

In  all  forms  of  cerebral  sclerosis,  the  meduUarj^  substance  is  most 
often  involved. 

Sections  of  a  sclerotic  patch  reveal  to  the  eye  a  moistened  surface, 
more  or  less  transparency,  and  small  bluish  or  reddish  spots.  The 
microscope  enables  us  to  detect  newly-formed  cells  in  abundance,  an 
excess  of  connective  tissue,  atrophy  of  the  nerve-fibres,  fatt}^  granules, 
scattered  amyloid  corpuscles,  and  a  thickening  of  the  coats  of  the  cerebral 
capillaries. 

Etiology. — Little  is  definitely  known  regarding  the  causes  of  cerebral 
sclerosis.  It  is  supposed  to  accompany'  chronic  cerebral  congestion 
and  morbid  changes  in  the  walls  of  the  capillary  vessels.  It  may  be 
developed  in  connection  with  epilepsy,  insanity,  idiocj',  bulbar  paralysis, 
tremor,  destructive  lesions  of  the  brain,  and  old  age.  Diffused  cerebral 
sclerosis  is  most  commonly  observed  during  infancy. 

Symptoms. — The  variety  of  sclerosis  which  exists  will  tend  to 
modify  the  symptomatologj^  of  this  disease. 

Tlie  diffused  form  occurs,  as  a  rule,  during  infancv.  It  is  usually 
accompanied  by  imperfections  in  development  of  both  mind  and  body, 
and  by  paralysis,  epileptic  convulsions,  and  post-paralytic  contractures. 
The  imperfections  in  development  are  generally  most  marked  upon  one 
side.  One  leg  or  arm  will  occasionally-  fail  to  grow,  or  it  may  grow 
slower  than  its  fellow. 

The  mental  faculties  exhibit  an  abnormal  dullness  (apj)roaching  to 
idiocy).  Articulate  speech  is  acquired  imperfectly  and  late;  again,  it 
may  never  be  developed.     In  some  recorded  instances,  where  the  disease 


SCLEROSIS   OF   THE   BRAIN.  331 

became  manifest  after  tlie  child  liad  learned  to  talk,  serious  imperfections 
of  utterance  were  occasioned  by  it. 

Later  in  the  disease,  the  limbs  begin  to  show  syin|)toms  of  paralysis. 
Still  later,  contractures  of  the  i)aralyzed  muscles  occur,  and  produce  de- 
formities of  the  limbs.  All  intuitive  or  acquired  sense  of  cleanliness  of 
habit,  or  attention  even  to  the  requirements  of  Nature,  seems  to  be  lost 
or  wanting  in  many  of  these  subjects.  The  urine  and  fa*ces  are  passed 
not  infre(][uently  in  the  clothing  or  bed. 

The  sensibility  of  the  limbs  is  apt  to  be  impaired  at  the  time  when 
paralysis  of  motion  is  developed.  It  is  most  marked  upon  one  side,  as 
a  nde. 

The  so-called  ''multiple  aclerosis^^  seldom  occurs  except  in  the  adult 
or  the  aged.  The  period  of  onset  is  frequently  marked  by  the  develop- 
ment of  numbness,  hyperjesthesia,  dysaesthesia,  and  other  sensor}^  dis- 
turbances, in  one  or  more  of  the  extremities,  for  many  months  before  the 
characteristic  trembling  appears.  Sometimes  these  j)atients  complain 
only  of  shooting  pains,  which  are  paroxysmal  and  of  short  duration, 
resembling  an  electric  shock.  Again,  an  eyjileptic  attack  may  occur.  In 
one  of  my  patients  the  disease  began  with  a  slight  attack  of  facial 
paralysis,  which  followed  a  heated  discussion  over  business  afiairs  with 
his  partners.  In  another,  attacks  of  "  petit  mal "  were  first  observed. 
These  were  followed,  after  the  lapse  of  a  few  years,  by  tremor  of  an 
aggravated  type. 

The  most  vharacteristic  symptom  of  this  disease  is  tremor.  It  de- 
velops gradually,  as  a  rule.  At  first,  the  patient  may  notice  only  a  slight 
tendency  of  some  limited  part  of  the  body  to  rhythmical  twitching.  It 
may  be  so  slight  in  the  beginning  as  to  attract  the  attention  of  the 
patient  only  when  quiet  and  unoccupied  ;  as,  for  example,  during  the 
moments  preceding  sleep.  I  have  known  it  to  be  limited  to  a  single 
muscle  of  the  leg  or  arm  for  many  months.  One  of  the  most  typical 
cases  which  I  have  ever  encountered  observed  it  for  over  a  year  in  the 
exterior  part  of  the  thigh. 

Gradually  these  convulsive  and  involuntary  twitchings  become  more 
aggravated,  and  are  diffused  over  a  larger  area. 

If  the  hand  be  affected,  its  movements  become  uncertain.  Such 
patients  often  become  afraid  to  dine  with  strangers,  on  account  of  their 
liability  to  accident  during  the  meal.  They  cannot  write  as  well  as 
before  the  trembling  commenced,  and  are  forced  after  a  while  to  discon- 
tinue all  attempts  to  carry  on  correspondence  or  book-keeping.  The 
constant  movements  of  the  extremity  render  them  the  objects  of  painful 
scrutiny  when  out-of-doors  or  among  strangers.  Dressing  and  undress- 
ing become  extremely  difficult.  One  of  my  patients  requires  the  aid  of 
a  body  servant  for  that  reason  alone.      Finally,  dynamographic  tracings 


332 


LECTURES    ON    NERVOl'S   DISEASES. 


will  show  an  inability  to  maintain  coiitiniiotis  contraction  of  the 
mnsclos. 

When  tlie  legs  become  attacked  the  <rait  closely  resembles  that 
of  paralysis  agitans  (page  163).  The  knee  and  foot  are  apt  to  move 
involuntarily  when  the  patient  is  sitting  or  reclining.  These  subjects 
fre(iiuMitly  acquire  the  hal)it  of  constantly  changing  the  position  of  the 
affected  limb  when  not  walking,  because  it  seems  to  produce  a  tcTii- 
porary  respite  from  trembling.  During  sleep,  the  shaking  ceases  for  a 
greater  or  less  period  of  time  ;  but,  finally,  the  movements  continue  day 
and  night.  F^xcitement  of  any  kind  and  muscular  effort  invariably  causes 
the  spasmodic  movements  to  become  markedly  intensilied. 

Occasionally,  the  eyes  and  face  become  affected  with  this  disordered 
condition  of  motility.     The  tongue  may  also  piirticipiite  in  the  tremor. 


Fig.  88. — Cerebral  Sclerosis.     (After  Fox  ) 

When  .symptoms  of  ataxia  are  induced,  we  haA-e  reason  to  believe 
that  the  fiUet-tracf  of  the  brain,  or  the  fiot^ferior  coJiimn.^  of  the  spinal 
cord  are  involved.  I  once  saw  a  case  where  the  patient  could  not 
respond  to  any  of  the  tests  for  coordinated  movements  of  one  arm  (page 
180),  but  could  use  the  opposite  arm  and  the  lower  limbs  perfect!}'. 

Paralysis  of  motion  or  sensation  is  apt  to  follow  the  development 
of  tremor.  The  limbs  are  not  usually  completely  jjiiralyzed.  They  are 
more  or  less  paretic. 

The  sense  of  touch  and  the  conscious  apprecintion  of  jmin,  tempera- 
ture, pressure  and  the  muscular  sense  may  be  disturbed  to  a  greater  or 
less  degree. 

The  special  senses  may  be  impaired  late  in  the  disease.  Smell,  sight, 
taste,  and  hearing  have  been  known  to  be  individually  destroyed. 


SCLEROSIS   OF   THE   BRAIN.  333 

The  condition  known  ns  the  "clKjked  disk"  (page  322)  may  be 
detected  by  the  ophthalmoscope  in  some  cases. 

Finally,  these  patients  grailually  become  unable  to  perform  any 
mental  or  physical  effort.  They  give  evidences  of  mental  decay  by  their 
inability  to  retain  urine  or  faeces,  a  loss  of  memory  and  of  mental  con- 
trol, dementia,  a  disregard  of  surroundings,  etc.  Death  may  occur  from 
general  convulsions,  exhaustion,  coma,  or  some  complicating  disease. 
The  duration  of  this  disease  may  vary  between  the  limits  of  a  few  months 
to  ten  years.     It  seldom  exceeds  tive  or  six  years. 

Differential  Diagnosis. — This  condition  may  be  confounded  with 
chorea,  paralysis  agitans,  the  tremor  which  follows  cerebral  hemorrhage, 
and  spinal  sclerosis. 

Chorea  is  occasionally  developed  in  adults.  It  is  never  associated, 
however,  with  the  head-symptoms  of  sclerosis  due  to  cerebral  congestion, 
such  as  vertigo,  pain  in  the  head,  etc.  The  peculiar  gait  of  cerebral  scle- 
rosis is  never  encountered  in  chorea.  The  spasmodic  movements  of 
chorea  are  irregular,  and  ditfer  markedly  from  the  rhythmical  movements 
of  tremor.  Impairment  of  sensation  or  motility  is  not  developed  in  con- 
nection wnth  chorea.  Feebleness  of  intellect,  when  jjresent,  appears 
during  the  early  stages  of  chorea. 

On  the  other  hand,  the  diti'used  variety  of  cei-ebral  sclerosis,  although 
confined  almost  exclusively  to  children,  is  characterized  by  symptoms 
of  idiocy,  convulsions.  hemi})legia,  etc.  It  could,  thei-efore.  hardly  be 
confounded  with  chorea. 

Paralysis  agitans  is  not  accompanied  by  evidences  of  impairment 
of  sensibility  or  motility  in  the  limbs ;  nor  are  the  ''  head-symptoms  "  of 
cerebral  sclerosis  developed  whenever  the  tremor  is  due  to  a  purely 
functional  disturbance.  Patients  with  functional  paralysis  agitans  can 
usually  cause  the  dynamograph  to  exhibit  a  tracing  of  continuous  mus- 
cular contraction.  This  is  impossible  in  subjects  atfected  with  multiple 
cerebral  sclerosis. 

To  my  mind,  however,  many  cases  of  sclerosis  are  diagnosed  as 
paralysis  agitans.  It  is  easy  to  understand  why  this  should  be  so.  Both 
are  liable  to  exist  after  middle  life  ;  both  cause  marked  tremor;  and  the 
gait  of  the  two  diseases  are  nearly  identical. 

Post-paraJijtic  tremor  is  to  be  diagnosed  by  the  history  of  the  case. 
Unlike  that  of  cerebral  sclerosis,  the  tremor  follows  the  development 
of  paralysis.  Post-paralytic  tremor  is  more  liable  to  follow  lesions 
of  the  internal  capsule  of  the  cerebrum  than  of  the  cortex ;  hence  the 
history  will  point  probably  to  a  simultaneous  imi^airment  of  sensation 
as  well  as  of  motion  in  one  lateral  half  of  the  body  at  the  time  of  the 
attack,  and  possibly,  also,  to  a  disturbance  of  the  function  of  smell, 
sight,  hearing,  or  taste.     The  ophthalmoscope  may  reveal  the  condition 


334  LECTURES    ON   NERVOUS   DISEASES. 

known   us   a  ■•choked    disk."      'I'liis    has    l)een  described   on  a  previous 
page. 

Spinal  S('le7'ofiiii  can  be  excluded  1)V  the  history  of  the  case.  Of 
course,  all  "  head-symptoms  '  would  be  absent.  The  evidences  of  mental 
decay  would  not  be  developed.  The  cranial  nerves  woidd  escape.  The 
evidences  of  impairment  of  sensibility  or  motility  would  be  irregularly 
manifested  in  the  limbs,  in  accord  with  the  seat  and  extent  of  the  sclerotic 
patches. 

Prognosis. — The  diffused  variety ,  when  occurring  in  infants,  is  almost 
invariably  fatal.  When  it  is  developed  in  the  adult  the  symptoms  may 
sometimes  be  ameliorated  by  judicious  treatment,  and  I  doubt  if  a  cure 
was  ever  complete. 

The  multiple  variety  perhaps  offers  a  little  more  hope  of  cure.  Still, 
it  must  be  confessed,  I  think,  by  all  who  have  experimented  in  these 
cases,  that  a  very  large  proportion  grow  steadily  worse  and  die  in  spite 
of  all  remedial  measures.  One  thing  is  certain  to  my  mind,  viz.,  that  ail 
benefit  which  can  be  expected  must  be  derived  from  active  treatment  in 
its  early  stages.  Hence  a  prompt  diagnosis  is  essential  if  a  hope  of  relief 
is  to  be  extended  to  the  patient  with  any  prospect  of  its  realization. 

Treatment. — Among  the  remedial  agents  which  have  been  suggested 
for  this  disease,  may  be  mentioned  the  chloride  of  barium  combined  with 
hyoscyamus  (Hammond),  the  bichloride  of  mercury  (Mitchell),  the 
phosphate  of  zinc,  the  chloride  of  iron,  the  nitrate  of  silver,  strychnia, 
cod-liver  oil,  and  electricity.  I  would  add  to  these  the  internal  adminis- 
tration of  hot  water  and  the  removal  of  all  recognized  sources  of  reflex 
irritation. 

Hammond  claims  tliat  great  benefit  may  be  derived  from  the  admin- 
istration of  a  graiv  of  the  barium  salt  three  times  a  day.  when  employed 
in  conjunction  with  the  tincture  of  hyoscyamus  in  doses  of  one  or  two 
drachms  three  times  a  day.  His  suggestion  that  the  chloride  of  barium 
be  fresh  and  properly-  prepared  seems  to  me  particularly  well  taken.  It  is 
an  unstable  salt,  and  is  difficult  to  obtain.  If  not  a  reliable  preparation, 
it  is  inert. 

I  have  found  that  it  acts  favorably-  (as  does  also  the  nitrate  of  silver 
and  strychnia)  upon  tremor.  It  also  tends  to  diminish  disorders  of  sen- 
sation and  motility  in  some  cases.  On  account  of  these  effects,  it  is 
indicated  in  cerebral  sclerosis. 

The  mercurial  treatment,  in  the  form  of  baths,  hypodermic  injection 
(page  290),  the  bichloride,  etc.,  is  indicated  when  a  syphilitic  history  can 
be  obtained.  1  do  not  believe  that  small  doses  of  mercurial  salts  arrest 
the  new  connective-tissue  formation  of  nerve-centres. 

Strychnia,  nitrate  of  silver,  iron,  and  fod-liver  oil  may  be  emplo3'ed 
either  as  substitutes  for  the  chloride  of  barium  or  as  tonics.     The  first 


CEREBRAL   ATROPHY.  335 

two  have  a  decided  anti-spasmodic  action.  A  moderate  (Quantity  of 
alcoholic  stimuhmts  with  meals,  and  exercise  in  the  open  air  (if  tempered 
with  judgment)  are  often  beneticial,  and  should  be  employed  as  adjuncts 
to  the  other  methods  of  treatment  mentioned. 

Electricity  is  employed  by  me  in  all  cases  where  tremor  exists.  It 
is  my  custom  to  apply  the  galvanic  current  (derived  from  five  or  ten 
milliamperes  of  current  to  the  head,  passing  it  from  the  forehead  to  the 
occiput.  Hammond  recommends  the  stimidation  of  the  main  sympathetic 
cords.  This  can  be  best  accomplished  b}-  placing  the  poles  at  the  neck. 
1  am  in  the  habit  also  of  using  from  ten  to  twenty  milliamperes  upon  the 
tremulous  muscles,  one  pole  being  placed  at  the  nape  of  the  neck.  Further 
directions  relating  to  the  electrical  treatment  of  tremor  will  be  given  later. 

When  paralysis  has  been  developed  the  faradaic  current  should  be 
substituted  for  the  galvanic,  as  a  remedial  agent  to  the  paralyzed  muscles, 
or  the  static  spark  should  be  administered. 

For  reasons  previously  given,  I  believe  that  the  internal  adminis- 
tration of  hot  water  (page  248)  exerts  a  marked  efliect  upon  all  diseases 
where  the  sympathetic  system  is  at  fault.  I  should  advise  that  it  be 
tried  upon  these  subjects. 

Finally,  all  mental  efforts  of  a  laborious  kind  should  be  forbidden. 
Emotional  excitement  of  any  kind  should  also  be  carefully  guarded 
against. 

CEREBRAL  ATROPHY. 

This  condition  may  be  of  two  varieties, — the  infantile  and  senile. 

Morbid  Anatomy. — In  the  infantile  form,  IhQ  characteristic  lesions 
include  (1)  obliquity  of  the  skull,  one  lateral  half  being  shrunken  and 
deformed;  (2)  a  premature  closure  of  the  sutures;  and  (3)  atrophy  of 
the  corresponding  cerebral  hemisphere,  involving  its  convolutions  and 
basal  ganglia. 

The  atrophic  changes  may  extend  to  the  pedicles  of  the  brain,  the 
pyramids  of  the  medulla,  and  the  columns  of  the  spinal  cord. 

This  form  is  due  chiefly  to  foetal  apoplexy,  encephalitis,  hydroceph- 
alus, and  physical  shocks  or  violent  emotions  on  the  i)art  of  the  mother 
during  pregnancy. 

In  the  senile  variety,  the  atrophic  changes  may  be  due  to  any  cause 
which  tends  to  slowly  impair  the  nutrition  of  the  brain.  Among  such 
may  be  mentioned  embolism,  thrombosis,  hemorrhage,  tumors,  encepha- 
litis, inflammations  of  the  pia  mater,  alcoholic,  opium-  or  lead-poisoning, 
syphilis,  and  excessive  venery  (?). 

Etiology. Something  has  already  been  said  respecting  the  probable 

causes  of  the  two  varieties.     The  fact  that  pathological  changes  in  the 
meninges    are    generally    found    to    coexist    with    cerebral    atrophy — 


336  LECTURES   ON    NERVOUS   DISEASES. 

especially  in  that  form  which  occurs  in  connection  with  the  so-called 
'' (jeneral  parabjsis  of  the  insane'' — is  wortliy  ot*  remark  as  shedding 
some  light  upon  tlie  causation  of  the  disease  in  individual  cases.  Senile 
marasmus  is  one  of  the  chief  causes  of  this  condition  wiien  occurring  in 
the  aged.     Males  are  more  frequently'  attacked  than  females. 

Symptoms. — The  symptoms  of  the  infantile  varietij  vary  witli  the 
extent  of  tlie  atrophy.  Weakness  of  intellect,  deaf-mutism,  ai)olition  of 
some  of  the  special  senses,  incomplete  paralysis,  muscular  contractures, 
and  impairment  of  the  sensibility  of  the  paralyzed  parts  may  be  present, 
in  addition  to  the  cranial  deformity.  The  bones,  muscles,  nerves,  etc.,  of 
the  side  opposite  to  the  cerebral  atrophy  may  be  imperfectly  developed. 
Ptosis,  and  strabismus  often  occur. 

The  peculiarities  in  the  appearance  of  the  cranial  bones  (enumerated 
in  the  preceding  lines j  would  naturally  suggest  the  presence  of  this 
morbid  condition.  Not  only  is  the  skull  misshapen,  but  the  bones  are 
apt  to  become  altered  in  their  relative  size  and  thickness. 

The  symptoms  of  the  ?.enile  form  include  many  manifestations  of 
enfeebled  mental  powers.  The  memory  and  intelligence  are  atfected 
enrly ;  apath}^  and  somnolence  develop ;  the  power  of  motion  is  slowly 
but  gradually  lost;  tremor  makes  its  appearance;  finally,  the  patients 
take  to  their  beds  and  pass  into  the  condition  of  childishness,  accom- 
panied by  the  symptoms  of  bulbar  paralysis,  from  which  they  die. 
Bed-sores,  bronchitis,  and  acute  pulmonary  oedema  are  frequent  com- 
plications. 

Differential  Diagnosis. — The  senile  form  might  possibly  be  con- 
founded with  cerebral  softening  and  apoplexy.  The  history  of  the  ease 
and  a  careful  study  of  the  symptoms  would  rapidly  dispel  all  doubts. 

The  infantile  variety  can  hardly  be  confounded  with  any  other  con- 
dition. The  spasmodic  attacks  and  the  paralysis  which  occur,  not  to 
speak  of  the  cranial  distortion,  are  sutRcicnt  for  a  diagnosis. 

Prognosis. — The  infantile  variety  usually  results  in  death  before  the 
fifth  year.  The  senile  form  is  apt  to  be  associated  with  intercurrent  dis- 
eases which  hastens  death,  among  which  may  be  mentioned  various  pul- 
monary complications,  bed-sores,  and  renal  or  vesical  diseases.  When 
the  condition  exists  in  connection  with  the  "general  i)aralysis  of  the  in-  fl 

sane,"  the  duration  of  life  seldom  exceeds  one  year. 

Treatment. — General  hygienic  measures  are  indicated  in  order  to 
increase  the  physical  vigor.  Massage  may  be  substituted  for  active 
physical  exercise,  when  the  patient  is  unable  to  walk  with  ease.  Gal- 
vanism is  sometimes  of  benefit.  The  bowels  and  bladder  should  be 
looked  after  if  the  patient  be  old.  I  do  not  believe  in  the  curative  effects 
of  the  iodides,  calabar  bean,  cold  douches,  tepid  baths,  etc.,  although  they 
have  been  recommended. 


CEREBRAL  HYPERTROPHY.  337 


CEREBRAL  HYPERTROPHY. 


This  disease  is  comparatively  rare.  We  owe  most  of  our  knowledge 
concerning  it  to  Virchow,  who  published  the  results  of  autopsies  and 
deductions  concerning  its  pathological  changes.  It  is  not  a  true  hyper- 
trophy, because  the  connective-tissue  elements  are  alone  increased. 

Morbid  Anatomy. — The  cranial  bones  are  abnormally  thin,  and  the 
liinin  protrudes  when  the  calvaria  is  removed.  An  enormous  increase 
in  the  circumference  of  the  head  is  present  when  the  disease  attacks  a 
child,  and  the  sutures  fail  to  close.  In  these  respects  it  resembles  chronic 
liydrocephalus.  The  brain  is  abnormally  heavy,  and  is  rendered  abnor- 
mally tough  and  elastic.  It  is  very  antiemic ;  the  ventricles  are  found  to 
be  emi)ty  ;  the  membranes  are  dry  and  attenuated;  the  convolutions  are 
comi)ressed  and  flattened  ;  and  the  dura  may  be  firmly  adherent  to  the 
skull.  The  cerebral  hemispheres  are  more  often  attacked  than  the  basal 
ganglia,  the  pons,  the  cerebellum,  or  the  medulla. 

Etiology. — When  not  congenital,  it  usually  attacks  a  child  before 
the  third  year.  It  seems  to  be  hereditary  in  some  instances.  It 
accompanies  idioc}',  and  may  follow  plumbism,  traumatism,  rickets, 
alcoholism,  and  epilepsy.  It  sometimes  occurs  in  adults.  Dwarfs  seem 
to  be  particularly  predisposed  to  its  development.  It  may  accompany 
insanity. 

Symptoms. — Wlien  present  in  the  child,  the  head  is  apt  to  lean 
toward  one  side,  and  a  tottering  gait  or  tremor  may  be  developed. 
Sometimes  there  are  conA'ulsions,  strabismus,  feebleness  of  mind  or 
i<1iocy,  somnolence,  protrusion  of  the  tongue,  and  severe  headache.  The 
thymus  gland  may  become  enlarged  and  cause  spasm  of  the  larynx.  In 
the  ttnal  stage  coma  develops.  It  is  generally  preceded  by  dilatation  of 
the  pupils,  vomiting,  convulsions,  and  a  slow  pulse. 

When  adults  are  attacked,  vomiting,  dyspnoea,  and  difficulty  in 
swallowing  are  developed  in  connection  with  delirium,  vertigo,  epilepti- 
form attacks,  headache,  and  abnormalities  of  the  heart's  action. 

Differential  Diagnosis. — It  is  impossible,  in  some  cases,  to  distin- 
guish between  this  disease  in  a  child  and  chronic  hydrocephalus.  The 
l)resence  of  a  cerebral  souffle,  pulsation  of  the  fontanelles,  and  a  previous 
lirecocity  of  the  child  point  to  cerebral  hypertrophy. 

Prognosis. — It  is  always  fatal.  In  the  child  progressive  stupor  de- 
velops. In  adults,  complications  are  more  liable  to  shorten  the  course 
of  the  disease. 

TUMORS   OF   THE   BRAIN   AND   ITS    ENVELOPES. 

The  various  forms  of  new  growths  which  may  be  encountered  in  the 
brain  have  been  enumerated  in  a  tabulated  form  on  page  218.     All  of  the 

23 


338  LECTURES   ON   NERVOUS   DISEASES. 

attempts  wliicli  have  been  made  to  classify  tumors  of  the  nervous 
system,  from  that  of  Jaceoud  to  the  present  time,  are  more  or  less 
illogical.  Every  classification  must  be  open  to  some  olyection,  but 
attempts  of  that  kind  uncaiestionably  serve  to  assist  memory  and  to 
systematize  description. 

We  have  already  touched  upon  aneurisms  as  one  of  the  lesions  of 
the  vascular  apparatus.  Parasites  of  the  brain  (which  are  enumerated 
by  Jaceoud)  are  discarded  by  Fox,  because  thev  can  hardl}-  be  said  to 
constitute  a  tumor.  Exostoses  should  be  discussed  among  the  tumors 
of  bone,  rather  than  in  this  connection,  although  they  may  develop  in 
the  brain  and  its  coverings. 

Morbid  Anatomy. — Among  the  entire  list  of  cerelual  neoplasms, 
gummata  [syphilitic  tumors)  possess  more  clinical  interest  than  any  of 
the  others.  This  is  because  they  are  more  frequent  than  the  rest,  and 
also  because  the  prognosis  is  favorable, — often  after  the  most  severe 
effects  to  the  brain  are  manifested. 

1.  We  owe  much  of  our  knowledge  of  syphilitic  tumors  to  Broad- 
bent,  who  has  studied  their  effects  upon  the  nerve-centres.  They  start 
from  the  membranes  or  attack  the  surface  of  the  brain  directly.  They  are 
strictly  localized  and  grow  slowly.  They  usuall}^  affect  onl^'  small  por- 
tions of  the  organ.  Gradually  they  tend  to  induce  adhesions  of  the 
membranes,  both  to  each  other  and  to  the  brain  itself;  and,  by  pressure, 
they  cause  local  softening  of  the  brain-substance.  The  effects  of  pressure 
upon  the  cranial  nerves  which  lie  adjacent  to  these  tumors  are  apt  to 
be  also  exhibited  early,  and  thus  the  diagnostician  is  enabled  to  locate 
the  tumor.  This  statement  applies,  however,  with  equal  force  to  all 
tumors  of  the  brain. 

Gummata  appear  as  reddish-gray,  jelly-like  masses,  which  are  infil- 
trated, as  it  were,  into  the  brain-tissue. 

2.  Perhaps  the  most  common  form  of  cerebral  tumor  is  tubercle. 
The  pathology  of  this  form  of  deposit  has  been  discussed  already  at 
some  length  in  the  pages  devoted  to  tuberculous  meningitis.  It  tends, 
as  a  rule,  to  invade  several  regions  at  the  same  time, — when  deposited 
within  the  substance  of  the  brain.  Tubercular  masses  in  the  aggregated 
form  may  be  of  different  sizes.  They  vary  from  that  of  a  small  pea  to  the 
dimensions  of  a  cherry,  or  even  of  a  small  hen's  egg.  They  are  sometimes 
encapsulated,  being  separated  entirely  from  the  cerebral  substance. 
Again,  the  line  of  demarkation  of  the  deposit  may  be  indistinctly  defined 
from  that  of  the  gray  or  white  matter.  Caseous  degeneration  is  not  infre- 
quently encountered  in  the  central  portions  of  these  tubercular  masses. 
Similar  deposits  are  apt  to  be  found  simultaneously  in  other  viscera  and 
tissues.  Tubercle  of  the  brain,  when  softened,  might  easily  be  mistaken 
for  a  gummatous  deposit.     The  examination  of  the  viscera,  the  history 


TUMORS   OF   THE   BRAIN   AND    ITS    ENVELOPES. 


339 


of  the  case,  and  a  microscopical   cxaniiiiation,  would  dispel   any    sucii 
elements  of  doubt. 

3.  The  brain  or  its  envelopes  may  become  the  seat  of  carcinoma  or 
cancerous  growths.  Scirrhus  and  encephaloid  are  the  more  common 
types.  Occasionally  the  melanotic  variety  is  detected.  Old  age  seems 
to  be  a  factor  in  the  development  of  cancer  of  the  brain  in  most  cases. 
It  may  start  either  in  the  brain-substance,  the  meninges  (chiefly  in  the 
pia),  or  in  the  bony  skull-cap. 

The  size  and  rapidity  of  progress  of  carcinomata  of  this  region 
depends  upon  ihe  type.  The  encephaloid  variety  grows  rapidly,  is  very 
vascular,  and  may  attain  an  immense  size.  The  scirrhous  type  is  of 
slower  growth,  and  is  less  vascular. 

4.  Regarding  other  varieties  of  cerel)rul  tumors  which  have  been 
•numerated  iu  tlie  preceding  table  (page  218),  it  does  not  seem  to  me 


Fig.  89. — Cerebral  Glioma. 

necessary  to  describe  the  microscopical  appearances  of  each,  because  most 
of  the  works  on  pathology  afford  all  necessary  information  respecting 
them.  It  may  be  well,  however,  to  mention  a  few  facts  pertaining  to 
each  which  possess  a  clinical  value. 

Cysts  of  the  brain  are  generally  the  result  of  an  old  apoplectic  clot 
which  has  undergone  certain  morbid  changes  already  described. 

Glioma  are  formed  of  connective-tissue  elements  of  the  brain  ;  hence 
they  are  usually  developed  in  the  substance  of  the  organ. 

Epithelial  growths  may  spring  from  the  cerebral  vessels  or  the  walls 
of  the  ventricles,  as  well  as  from  the  cells  of  the  pia  and  arachnoid.  This 
statement  does  not  comprise  those  epithelial  tumors  which  are  properly 
classed  as  cancerous. 


340  LECTURES    ON   NERVOUS   DISEASES. 

Fsammoma  or  sand-tumoi-K  consist  of  granules  of  carbonate  of  lime 
held  in  a  matrix  of  connective-tissue,  in  whose  meshes  concentric  layers 
of  epithelial  cells  are  also  found.  (Virchow.)  They  are  encountered 
chiefly  in  the  dura  (particularly  in  that  part  which  covers  the  parietal 
lobe)  and  in  the  choroid  plexus  of  the  fourth  ventricle. 

Gholesteatomata,  or  pearl-tumor h^  are  composed  of  cholesterine  and 
stearine.  They  are  destitute  of  vessels.  Their  size  is,  as  a  rule,  small. 
They  are  known  to  arise  from  the  bones,  meninges,  and  in  the  brain  itself. 

Tumors  of  the  osseous  type  spring,  as  a  rule,  from  the  calvaria.  In 
rare  instances,  however,  they  do  not  do  so.  The  falx  is  sometimes  more 
or  less  osseous.  True  ossific  deposits  have  been  encountered  within  the 
brain-substance.  I  lately-  discovered  one  in  the  brain  of  an  epileptic 
patient. 


Fig.  90. — Syphilis  op  the  Bkain.    (Aft^^rFox.) 

Fibrous,  fibro-pJastie,  and  faff;/  r/rou'fhs  within  the  skull  are  to  be 
classed  as  accidental  neoplasms.  The  fibro-plastic  variety  has  been 
known  to  attain  the  size  of  an  orange.  (Hammond.)  The  consistence 
of  these  tumors  is  subject  to  extreme  variations.  Fibrous  tumors 
are  rare,  but  they  may  arise  from  the  ependyma  of  the  ventricles. 
Lebert  reports  seventeen  to  have  deA'eloi)ed  simultaneously  within  the 
lateral  ventricle. 

Hydatids  (when  present)  are  generally  detected  within  the  cerebral 
hemispheres.  The  parasite  {echinococcus)  is  enveloped  in  a  cyst,  which 
may  be  as  large  as  an  orange.  The  number  of  such  cysts  is  usuallj' 
small.     They  are  often  solitary. 

Another  form  of  parasitic  tumor  (due  to  the  cysticercus)  may  be 
encountered  within  the  brain-substance.  The  surrounding  cyst  is  usually 
wantino;  in  this  varietv.     They  lie  near  to  the  surface  of  the  brain,  as  a 


TUMORS   OF   THE  BEAIN  AND   ITS  ENVELOPES.  341 

rule.  Sometimes  they  are  found  iu  the  ventricles  and  pia.  They  are 
seldom  solitary.  Cruveilhier  reports  a  case  where  over  one  hundred  were 
found. 

Vascular  tumors  of  the  miliary  type  have  been  discussed  in  connec- 
tion with  the  morbid  anatomy  of  cerebral  hemorrhage.  It  may  be  well, 
however,  to  mention  the  statistics  of  Gouguenheim  (as  quoted  by  Ham- 
mond) respecting  the  relative  frequenc}^  of  aneurismal  dilatations  of  the 
more  important  vessels.  This  author  found  that  out  of  69  cases,  seven- 
teen aflected  the  basilar ;  fourteen  attacked  the  middle  carotid  ;  twelve 
involved  the  internal  carotid ;  eight,  the  anterior  cerebral ;  five,  the 
posterior,  or  communicathig ;  four,  the  cerebellar;  three,  the  posterior 
cerebral ;  and  two,  the  anterior  communicating  and  the  middle  meningeal. 

M.  P.  Jacobi  has  lately  contributed  a  classical  article  on  the  subject 
of  cerebral  tumors,*  a  study  of  which  will  well  repay  the  reader. 

Etiology. — Much  that  has  been  said  already  respecting  the  morbid 
anatomy  of  cerebral  tumors  relates  to  their  causation  as  well. 

Large  aneurismal  tumors  usually  occur  after  the  age  of  fifty,  and 
are  preceded  by  textural  changes  in  the  arterial  walls  (atheroma,  fatty 
degeneration,  etc.).  In  such  cases,  the  exciting  causes  of  the  aneurism 
ma}'  include  all  forms  of  traumatism  to  the  head  or  bod}^,  cardiac  hvper- 
trophy,  prolonged  anxiety  or  emotional  excitement,  excessive  mental 
labor,  embolism,  etc. 

Cancerous  growths  may  occur  at  any  age,  but  they  are  most  com- 
monly encountered  in  male  adults.  It  may  be  excited  by  traumatism 
(according  to  Hammond). 

Tubercular  deposits  within  the  skull  are  most  frequently  encountered 
in  the  young.  They  may  occasionally  be  developed  during  adult  life,  as 
a  sequel  of  similar  deposits  within  the  lungs  or  other  viscera,  and  after 
infection  from  caseous  masses  in  the  viscera,  joints,  glands,  etc. 

Gummata  are  invariably  due  to  syphilitic  infection.  They  are 
developed  late  in  the  disease,  as  a  rule. 

Parasitic  tumors  are  due  to  the  transportation  of  the  embryos  from 
some  distant  part. 

Symptoms. — It  must  be  evident  to  the  reader  that  the  symptoms 
of  a  cerebral  tumor  necessarily  depend  upon  three  factors,  viz.,  its  seat, 
its  rapidity  of  growth,  and  the  amount  of  pressure  or  injury  created  by  it 
upon  the  cortical  cells  or  nerve-tracts  which  lie  in  close  proximity  to  it. 
I  would  refer  the  reader,  therefore,  to  a  preceding  section  which  treats 
of  the  localization  of  lesions  of  special  areas  of  the  cortex  and  the  more 
important  component  parts  of  the  cerebral  architecture  ;  as  well  as  to 
those  pages  also  which  deal  with  cerebral  thermometry,  the  use  of  the 
ophthalmoscope,  and  the  symptomatology  of  cerebral  hemorrhage. 
*  Reference  Handbook  of  Medical  Sciences,  vol.  i.  p.  668. 


342  LECTUKES   ON   NERVOUS   DISEASES. 

It  should  be  remembered,  however,  that  the  slow  growth  of  a  cere- 
bral tumor  does  not  allow  of  pressure-effects  upon  neighboring  parts  as 
rapidly  as  would  an  apoplectic  extravasation,  although  in  time  it  might 
create  even  more  serious  damage. 

Again,  the  presence  of  a  tumor  of  the  meninges  or  bone  might  at 
first  cause  symptoms  of  irritation  of  the  cortex  (Jacksonian  epilepsy', 
frequent  convulsions,  etc.).  Later  on,  other  symptoms,  which  would  be 
apt  to  appear,  would  indicate  a  destruction  of  the  functions  of  parts 
which  at  first  were  only  irritated  by  the  slight  pressure  upon  them 
exerted  from  the  growth  of  the  neoplasm. 

Third,  the  vascularity  of  the  tumor  and  the  activity  of  the  circula- 
tion required  to  insure  its  development  would  be  apt  to  create  modifica- 
tions in  the  temperature  of  the  scalp  over  the  seat  of  the  tumor,  provided 
it  was  superficially  situated. 

Fourth,  we  would  be  apt  to  notice  that  the  steady  increase  in  size 
of  the  growth  would  progressively  impair  one  or  more  of  the  cranial 
nerves,  and  possibly  some  of  the  tracts  of  nerve-fibres  which  help  to 
form  the  cerebral  hemispheres. 

Fifth,  tumors  of  the  brain,  and  in  fact  any  lesion  which  tends  slowly 
to  increase  intra-cranial  pressure,  tend  to  manifest  their  existence  by 
development  of  a  double  optic  neuritis, — the  so-called  "  choked  disk  " 
(Fig.  87). 

This  condition  is  only  apparent  when  the  ophthalmoscope  is  em- 
ployed, but  it  possesses  a  decided  clinical  value.  I  have  described  the 
condition  in  detail  in  a  brochure,  from  which  I  quote  as  follows : — 

"  When  the  radiating  fibres  of  the  internal  capsule  are  involved  in 
a  lesion  which  creates  a  gradually-increasing  pressure  (as  in  the  case  of 
tumors  which  grow  slowly),  the  y(//?rf»sq/"  the  eye  exhibits  morbid  changes 
in  the  region  of  entrance  of  the  optic  nerve  which  are  of  value  in  diag- 
nosis. The  condition  so  produced  is  commonly  known  as  the  'choked 
disk.'  It  is  nearly  alwa3's  bilateral,  but  often  most  marked  in  one  e3^e. 
It  may  be  considered  as  one  of  the  most  positive  signs  of  an  extensive 
intra-cerebral  lesion,  and  especially  of  tumors  of  the  brain.  When  the 
eye  is  examined  with  an  ophthalmoscope,  this  condition  is  characterized 
by  a  swollen  appearance  of  the  optic  nerve,  which  projects  appreciably 
above  the  level  of  the  surrounding  retina ;  the  margin  of  the  disk  is 
either  obscured  or  entirely  lost ;  the  arteries  appear  small,  and  the  veins 
large  and  tortuous ;  finally,  small  hemorrhagic  spots  may  often  be  de- 
tected in  the  retina  near  the  margins  of  the  disk.  In  spite  of  this  con- 
dition, the  power  of  vision  may  be  little  impaired  ;  so  tliat  the  existence 
of  '  choked  disk  '  may  be  unsuspected  unless  the  ophthalmoscope  be  used 
before  the  diagnosis  is  considered  final.  After  a  number  of  weeks,  and 
very  much  longer  if  a  tumor  is  the  exciting  cause  of  the  condition,  the 


TUMORS   OF   THE   BRAIN   AND   ITS   ENVELOPES.  343 

appearance  of  the  disk  changes.  An  unnatural  bluish-white  color,  which 
denotes  atrophic  changes,  develops  ;  the  outline  of  the  disk  becomes 
sliari)ly  defined ;  the  retinal  vessels  become  small,  and  vision  becomes 
markedl}^  interfered  M^ith." 

Differential  Diagnosis. — The  chief  points  by  which  the  existence  of 
a  cerebral  tumor  is  indicated  are  as  follow:  (1)  Severe  and  persistent 
pain  of  a  more  or  less  localized  t^'pe ;  (2)  the  occurrence  of  convulsive 
attacks,  which  may  or  may  not  be  followed  bv  transient  paralysis  and 
unconsciousness  ;  (3)  the  retinal  changes  of  optic  neuritis;  (4)  the  pres- 
ence of  monoplegia  or  the  paralysis  of  some  (one  or  more)  of  the  cranial 
nerves ;  (5)  the  history  of  the  case  when  syphilis,  tuberculosis,  or  the 
development  of  parasitic  cysts  are  suspected. 

Since  cerebral  softening  often  accompanies  the  development  of  a 
cerebral  tumor,  it  is  possible  that  all  the  symptoms  of  that  condition 
(except  the  choked  disk)  may  exist  and  render  the  diagnosis  more  or 
less  obscure. 

From  epilepsy  the  diagnosis  is  to  be  made  by  the  presence  of  intra- 
cranial pain ;  by  the  age  and  history  of  the  patient ;  by  the  fact  tliat  the 
convulsion  is  apt  to  be  more  or  less  unilateral,  and  to  start  in  that  par- 
ticular part  of  the  body  wliose  motor  centres  are  subjected  to  the  greatest 
amount  of  irritation ;  by  the  presence  of  consciousness  during  the  con- 
vulsive attack,  or  of  incomplete  coma ;  by  occasional  development  of 
transient  paralysis  after  the  fit ;  and  by  the  fact  that  the  mental  powers 
of  the  patient  are  seldom  weakened. 

From  the  multitude  of  causes  that  may  induce  hemiplegia^  mono- 
plegia, or  paralysis  of  some  cranial  nerve,  the  diagnosis  must  be  made 
by  exclusion,  after  the  facts  revealed  by  a  clinical  examination  of  the 
patient  (according  to  Section  II)  have  been  thoroughly  and  accurately 
determined. 

One  of  the  most  remarkable  cases  of  supposed  hysteria  that  ever 
came  under  my  observation  was  found  after  death  to  be  due  to  a  widely 
diffused  form  of  enchondroma  of  the  falx  cerebri. 

Prognosis. — Unless  of  the  syphilitic  type,  cerebral  tumors  are  liable 
to  cause  death  in  spite  of  treatment.  Lately,  cases  of  successful  re- 
moval of  a  cerebral  neoplasm  have  been  reported.  In  the  light  of  modern 
cerebral  localization  it  is  possible  that  surgical  measures  may  occa- 
sionally be  employed  with  benefit  to  the  patient  when  the  tumor  is 
non-malignant  and  superficially  situated. 

Gummata  are  unquestionably  absorbed  in  many  cases  when  the 
iodides  are  pushed  to  extreme  limits. 

Treatment. — The  remarkable  successes  in  treatment  of  syphilitic 
tumors  of  the  brain  or  its  envelopes,  which  are  frequently  repoi'ted, 
should  lead  us  to  carefully  investigate  the  question  of  syphilitic  infec- 


344  LECTURES   ON  NERVOUS  DISEASES. 

tion  in  every  case.  I  have  personally  witnessed  in  four  of  my  own 
patients  a  j)erfect  cure,  when  the  prognosis  appeared  to  be  extremely 
grave.  In  one,  hemiplegia  and  homonymous  hemianopsia  existed  ;  in 
another,  aphasia,  strabismus,  and  extensive  paresis  had  been  produced; 
in  a  third,  almost  total  blindness  existed  when  the  patient  was  first  seen 
by  me;  in  the  fourth,  complete  coma  suddenly  occurred  after  an  attack 
of  ocular  paralysis,  Avhich  was  accompanied  by  veiy  marked  mental  dis- 
turbance. Another  of  my  patients  had  several  convulsions  within  a 
week,  and  is  to-day  in  perfect  health. 

As  early  as  1872,  I  began  experiments  with  enormous  doses  of  the 
iodide  of  potash  and  the  iodide  of  calcium  in  these  cases.  To  one 
patient,  seen  by  Prof.  A.  L.  Loomis  with  me  in  consultation,  I  gave  an 
ounce  of  the  former  salt  daily  for  three  days.  I  have  frequently  given 
half  of  that  amount  dail}'  for  a  week  at  a  time,  or  until  the  effects  of 
iodism  became  very  marked.  With  some  patients,  who  bear  the  potash 
salt  badly,  I  employ  the  calcium  preparation  in  about  the  same  doses,  as 
I  have  found  that  it  creates  less  gastric  disturbance.  The  objection  to 
it  is  that  the  salt  decomposes  easily  and  free  iodine  is  liberated,  causing 
the  solution  to  become  of  a  brown  color.  Care  should  therefore  be 
exercised  in  using  the  pure  drug  and  in  exposing  a  solution  of  it  to  light. 

My  experience  is  strongly  in  favor  of  combining  mercurialization 
with  the  internal  administration  of  the  iodides  in  the  tertiary  as  well  as 
the  secondary  stages  of  syphilis.  I  prefer  the  mercurial  bath  and  the 
hypodermic  injection  method  to  the  administration  by  the  stomach, 
when  it  is  practicable  to  employ  them. 

When  the  tumor  is  of  the  aneurismal  type  the  use  of  the  iodide  of 
potash  in  moderate  doses  seems  to  exert  a  curative  influence  in  some  cases. 
It  is  well  to  keep  such  patients  in  a  recumbent  position,  and  to  avoid  all 
excitement  and  other  possible  causes  of  an  excessive  action  of  the  heart. 

Regarding  the  treatment  of  the  other  varieties  of  tumors  mentioned 
as  liable  to  exist  within  the  skull,  I  can  offer  but  little  encouragement. 
If  it  be  possible,  in  any  given  case,  to  decide  positively  respecting  the 
character  and  size  of  a  tumor  as  well  as  its  exact  seat,  and  if  none  of 
the  contra-indications  to  trephining  existed,  I  might  be  tempted  to 
employ  the  trephine.  So  far,  however,  I  have  never  encountered  a  case 
that  justified  such  a  measure  in  my  opinion. 

A  SUMMARY   OF   THE   SYMPTOMS   OF   CEREBRAL   DISEASES. 

As  an  aid  to  the  reader,  I  have  deemed  it  wise  to  add  to  this  chapter 
a  differential  table  of  the  more  common  symptoms  of  cerebral  diseases. 
Tables  of  this  kind  are  particularlj-  of  service  to  the  busy  practitioner 
in  reviewing  the  prominent  features  of  the  separate  diseases  which  have 
been  previously  described. 


SUMMARY   OF   THE   SYMPTOMS   OF   CEREBRAL   DISEASES. 


345 


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SECTION  IV. 


DISEASES   OF  THE   SPINAL   CORD  AND  ITS 
ENVELOPES. 


(341) 


i 


I 


SECTION  IV. 

DISEASES    OF   THE   SPINAL   COED. 

In  the  first  section  of  tliis  volume,  certain  anatomical,  physiological, 
and  clinical  deductions  have  been  given  respecting  various  component 
parts  of  the  spinal  cord.  It  is  very  important  that  the  reader  familiarize 
himself  thoroughly  with  these  before  he  attempts  to  master  the  symp- 
tomatology of  spinal  lesions. 

One  of  the  first  distinctions  that  must  be  drawn  respecting  spinal 
lesions  (in  order  to  make  accurate  diagnosis)  is  that  which  exists 
between  what  is  known  as  *'  systematic "  and  ''  non-systematic "  or 
"  focal  "  lesions  of  the  cord. 

By  "  systematic  "  lesions,  we  mean  any  pathological  condition  which 
tends  to  progress  along  definitely  recognized  subdivisions  of  the  spinal 
cord,  without  spreading  laterally  to  adjacent  parts. 

By  ^^nwn-systematic''''  or  '■'focal''''  lesions,  we  mean  any  pathological 
condition  which  tends  to  spread  laterally,  and  thus  to  involve  adjacent 
columns  of  the  cord  as  the  lesion  progresses. 

For  example,  a  systematic  lesion  of  the  anterior  horn  would  remain 
confined  to  the  anterior  horn,  irrespective  of  its  extent  up  or  down  the 
cord.  On  the  other  hand,  a  focal  lesion  starting  in  the  anterior  horn 
might  spread  to  any  of  tlie  various  subdivisions  which  lie  adjacent  to 
the  horn,  viz.,  the  column  of  Tiirck,  the  crossed  pyramidal  column,  the 
anterior  root-zone,  the  spinal  commissure,  etc.     (See  Fig.  91.) 

Clinicall}',  this  distinction  is  very  important.  A  systematic  lesion 
of  a  motor  column  would,  for  example,  yield  exclusively  motor  sj-mp- 
toms  during  the  life  of  the  patient,  while  a  focal  lesion  starting  in  a  motor 
column  might  subsequently  spread  to  a  sensory  column,  and  thus  occa- 
sion both  motor  and  sensory  symptoms  during  life. 

The  table  on  the  next  page  will  give  the  reader  a  knowledge  of  the 
more  important  spinal  diseases  which  are  to-day  clinically  recognized. 

It  must  be  remembered  that  the  spinal  cord,  like  the  brain,  consists 
of  two  anatomical  elements,  viz.,  nerve-cells  and  nerve-fibres. 

The  SPINAL  FIBRES  are  connected  with  the  spinal  cells  in  such  a  way 
as  to  allow  of  a  communication  (1)  between  the  spinal  cells  and  the 
periphery  of  the  body  (the  spinal  nerves) ;  (2)  between  the  cells  of  the 
cord  and  those  of  the  various  gray  masses  of  the  brain  {tlie  conducting 
tracts);  and  (3)  between  the  cells  of  the  difterent  spinal  segments  them- 
selves (the  associating  fibres  of  the  cord). 

(349) 


350 


LECTUIIES    ON    NEllVOUS   DISEASES. 


A  TABLK  OF  THE  ABNORMAL  STATES  OF  THE  SPINAL  CORD. 


seconuary  lo  a  iesi<>n  oi   me  di.iim  <ji  i;uiu). 

„    „..  „  C  I'liiiiuni — Usually 
SCLKUOSIS     OF     Till.  J       (,,.tanoi,l  imrapU 


Functional,  Diseases   of 

THE  COKD. 


A. 

Systematic   Lesions  ok   the 
Motor     Portions     of    the  S 
Cord— or   of   the    so-called 
"  Kincsodic  Syslein." 


B. 

Systematic  Lesions  of  the 
Sensory  Parts  of  the  Cord 
—or  of  the  so-called  '^  .Esthe- 
sodic  system." 


Non-Systematic  or  -'Focal"  - 
Lesions  of  the  Cord. 


Sclerosis  of  the  Direct  Pyramidal  Column  (usually 

secondary  to  a  lesion  of  the  bnim  or  cord). 

'   "  ///(ar.v— Usually  bilateral- 

tlc(jiu). 
,  ,,.  t.,#iu,>..../ — ^  .-.aaliy    unilat- 

COLUMNS.  \^     erix,l—(descendiiiy'cariety). 

Infla.mmation  of  the  Cells  of  the  An-  |  Acmte. 

TEKioH  Horns  of  the  Spinal  Gray  Sub--^^  Sub-acute. 

STANCE  (poliomyelitis  anterior),  3  varieties.    LChronic. 
Degeneration    of   the   Cells    of   the   Anterior 

HOKNS  (proqrcssive  muscular  atrophy). 
Pro(;ressive" Facial  Atrophy. 
Pseitdo-Hypertrophic  Paralysis. 
Amyotrophic  Lateral  Sclerosis. 
Central  Myelitis. 

Primary    Bilateral    Sclerosis    of   the   Postero- 

E.KTERNAL    AND    POSTERO-INTERNAL  COLUMNS    (loco- 
motor ataxia). 
Secondary    Unilateral  or  Bilateral   Degener- 
ation OP  the  Sensory  Coiatmns  {ascending  variety). 

rAcute  leptomeningitis  spinalis. 
T  rrt!  J  Chronic  "  '" 

Spinal  meningitis  -<  External  pachymeningitis  spinalis. 
^Internal  "  " 

rOf  the  bones. 

Spinal  Tumors S  Of  the  meninges. 

LUf  the  spnuil  cord. 


Spinal  Hemorrhage. 


Ila'mutoini/iiia. 
Hannatorrhae/iis. 


My'elitis 

Syringomyelia  and  Hydromyelia. 


;  Acute. 
Chronic 


Spinal  Irrit.\tion. 

C  Lead 
Functional      Para-  r  From  Hysteria.      Arsenic. 


plegia.. 
Thomson's  Disease. 


Poisons.    <  Phosphorus. 
I         "     Ana-mia.       Ergot. 
L  Alcohol. 


E. 

Vascular  Changes  (of  a  dif- 
fused or  circumscribed  char- 
acter). 


F. 
Congenital   Abnorm.\i 
OF  the  Cord. 


Spinal  Neurasthenia. 
Acute  Ascending  Paraly'sis. 
Writer's  Cramp. 

L    TET.VNY'. 

Spinal  Congestion  or  Hyi'er^mia. 

Spinal  An.emia. 

Spinal  Embolism. 

Atheroma  of  the  Vessels. 

Fatty   or    Amyloid    Degeneration    of   Arterial 

Coats. 
Aneurismal  Dil.\tations. 

r  Spina  Bifida  (with  alterations  in  the  cord). 

)    Absence  of  Spinal  Cord. 

I    Incomplete  Development  of  Spinal  Cord. 

L  Congenital  C.wities  of  the  Cord  (Syringomyelia). 


Thus  we  have  within  tlie  si)inal  cord  the  following  groups  of  fibres  : — 
1.   Those  which  constitute  the  aiUerior'^  and  pot^tei'ior  nerve-roots.^ 


*  The  fibres  of  the  anterior  nerve-roots  may  be  said  to  have  the  following  connections 
(indirectly,  of  course,  through  the  multipolar  cells  of  the  anterior  horn  of  the  corre- 
sponding side)  :  1,  with  the  lateral  motor  column  of  the  corresponding  side  of  tlie  cord  ; 
3,  with  the  anterior  motor  column  of  the  corresponding  side  of  the  cord ;  3,  with  the 
anterior  motor  column  of  the  opposite  side  of  the  cord,  by  means  of  fibres  which  decus- 
sate in  the  white  commissure. 

f  A  direct  continuity  of  some  of  the  fibres  of  the  posterior  nerve-roots  in  the  colnmii 
of  Goll  has  been  asserted  to  exist  by  Singer.  This  observer  detected  a  tract  of  degenera- 
tion iu  these  column^  extending  to  the  medulla  after  section  of  the  posterior  roots  in 
dogs. 


DISEASES   OF    THE   SPINAL   COKD. 


351 


They  pass,  of  necessity,  through  the  white  substance  of  the  cord  to  reach 
the  spinal  gray  matter. 

2.  Tlie  paths  of  motor  and  sensori/  conduction.  These  are  prolonged 
to  the  brain,  and  probably  do  not  enter  directly  into  the  formation  of 
the  spinal  nerve-roots, 

3.  The  associating  fibres.  These  do  not  extend  to  the  cerebrum  ; 
nor  do  they  leave  the  substance  of  the  cord.  They  simplj'  join  the 
various  spinal  segments  with  each  other. 


Fig.  91. — Diagram  Illustrating  the  Relations  of  the  Nerve-Fibre  Tracts  in  the 
Spinal  Cord. — The  section  is  supposed  to  be  taken  transversely  through  the  lower  part  of 
the  cervical  enlargement  (slightly  modified  trom  Flechsig):  A,  Anterior  median  fissure: 
B,  posterior  median  fissure;  C,  intermediate  fissure  ;  D,  anterior  gray  cornu  :  E,  posterior 
gray  corn u:  F,  gray  commissure,  with  central  canal;  G,  uncrossed  pyramidal  tract  (Flech- 
sig), or  column  of  TUrck  ;  H,  fundamental  part  of  the  anterior  column  (anterior  root-zones 
of  Charcot  and  his  pupils);  1,  anterior  part  of  lateral  column  ;  K,  crossed  pyramidal  tract 
of  lateral  column:  L,  direct  tract  from  lateral  column  to  cerebellum  ;  M,  column  of  Burdach, 
posterior  root-zones  of  Charcot  and  his  pupils;  N,  column  of  Goll ;  S,  sensory  tract  of 
Gowers.  The  posterior  columns  of  descriptive  anatomy  include  the  fields  M  and  N  extending 
on  the  surface  from  B  to  R.  The  antero-lateral  columns  extend  on  the  surface  from  R  to  A. 
Their  anterior  division  includes  the  fields  G  and  H  ;  their  lateral  division,  the  fields  K,  L, 
and  I.     Similar  colors  are  supposed  to  indicate  in  this  plate  a  similarity  of  function, 

4.  Trophic  and  vaso-motor  filaments.  These  connect  the  cells  of 
the  cord  (by  means  of  the  Spinal  nerve-roots)  with  the  blood-vessels  and 
the  organs  related  to  motion  and  sensation. 

We  can  therefore  draw  the  following  conclusions,  which  bear  upon 
diagnosis  : — 

Interference   with   the   function   of  the  first  and    second    of  these 


1 


352  LECTURES   ON   NERVOUS   DISEASES. 

groups  of  spinal  fibres  will  result  in  a  disturbance  (more  or  less  pro- 
found) of  tlie  patient's  capabilities  either  of  motion  or  of  perceiving  and 
recording  sensory-  impressions  of  various  kinds  (those  of  touch,  pain, 
temperature,  muscular  sense,  and  electrical  stimulation). 

Destruction  of  the  third  group  of  fibres  will  cause  s^-mptoms  of 
incoordination  of  movement. 

Impairment  of  the  functions  of  the  fourth  group  mav  create  abnor- 
malities in  the  calibre  of  blood-vessels,  and  an  unhealth}^  state  of  the 
skin,  hair,  nails,  muscles,  etc.  The  effects  of  spinal  lesions  upon  the 
pupil  (p.  411)  are  probably  attributable  to  the  vaso-motor  fibres. 

The  arrangement  of  the  cells  and  fibres  of  the  spinal  cord  are  very 
clearly  shown,  from  a  physiological  standpoint,  in  a  table  wnich  I  have 
prepared  (p.  355).  It  is  somewhat  similar  to  one  lately  published  by 
M.  A.  Starr. 

It  is  well  to  know  that  there  are  certain  symptoms  which  are  pecu- 
liarly apt  to  be  encountered  in  connection  with  spinal  diseases.  These 
may  be  separately  discussed  with  advantage  to  the  reader  prior  to  the 
description  of  the  separate  diseases. 

It  is  also  important  that  a  beginner  in  this  field  of  diagnosis 
should  grasp  certain  general  axioms  that  will  materially  aid  him  in 
discriminating  l)etween  focal  or  systematic  spinal  lesions  which  may  be 
creating  an  impairment  of  the  functions  of  one  or  more  of  the  groups  of 
fibres  just  described  or  the  horns  of  the  spinal  gray  matter. 

The"  following  paragraphs  and  table  may  possibh'  shed  some  light 
upon  the  diagnosis  of  spinal  diseases : — 

1.  Contracture  of  muscles,  when  present  in  a  case  afflicted  with 
paresis  or  paralysis,  points  strongh'  to  a  lesion  of  the  motor  fibres  in  the 
lateral  column  of  the  same  side  (the  "crossed  pyramidal  fibres''). 

2.  Exaggeration  of  the  tendon-reflexes  is  a  symptom  which 
points  to  the  same  conclusion. 

3.  Rapid  atrophy  of  muscles  (either  as  an  independent  affection  or 
as  a  sequel  to  paralysis)  points  to  a  diseased  condition  of  the  cells  of  the 
anterior  horn  of  the  spinal  gray  substance.  A  piece  of  muscle  (when 
bitten  out  by  means  of  Duchenne's  trocha  and  subjected  to  a  micro- 
scopical examination)  will  quickly  show  whether  atroph}'  is  occurring 
as  a  result  simply  of  disuse  or  of  organic  disease  of  the  nervous 
mechanism. 

4.  Abnormal  sensory  phenomena  (such  for  example  as  pain,  hyper- 
aesthesia,  anaesthesia,  analgesia,  formication,  numlmess,  tingling,  etc.) 
point  to  the  existence  of  a  lesion  which  affects  either  the  posterior 
nerve-roots  or  the  jesthesodic  portions  of  the  cord  (p.  93). 

5.  Diminution  or  abolition  of  the  reflexes  (p.  96)  points  to  lesion 
which  affects  a  reflex-arc  (Fig.  95). 


DISEASES   OF   THE   SPINAL   CORD.  353 

A  Table  of  Some  of  the  More  Important  Diagnostic  Symptoms  of  Spinal  Lesions. 


Contracture  (tonic 
shortening  of  muscle 
of  a  persistent  type). 


Atrophy  of  Muscles 
(due  to  fatty  degen- 
eration of  the  sarcous 
elements). 


Exaggerated    Re- 
flexes. 


Diminution    or   Abo- 
lition   OF    Spinal 

E-EFLEXES. 


Trophic  Disturbances.  ' 


Abnormal     Sensory 
Phenomena. 


part  OF  spinal  cord 
affected. 


f  (1)  Generally  due  to  an  im- 
plication   of  the    "  crossed- 
I     pyramidal  fascicidi"  (Fig. 
\      32). 
(2)  May  possibly  tollow   (?) 
implication  of  the  fibres  of 
Turck's  column  (Fig.  32). 


f  (1)  Is  generally  due  to  a 
lesion  confined  to  the  cells 
of  the  anterior  horn. 
(2)  It  may  follow  a  severance 
of  the  motor  fibres  which 
compose  the  anterior  nerve- 
roots. 


Occurs  from  implication  of 
the  motor  bundles  of  the 
lateral  column,  as  a  rule. 

'  (1)  Usually  occurs  with 
lesions  of  the  posterior 
columns  of  the  cord  (loco- 
motor ataxia). 
(2)  Lesion  of  the  posterior 
nerve-roots  may  also  cause 
this  symptom. 

f  Lesions  of  the  gray  substance 
I      of  the  cord  are  particularly 

liable    to   cause  symptoms 

of  this  variety. 

'  (1)  May  indicate  either  an 
irritative  or  a  destructive 
lesion  of  the  cord. 

(2)  The  posterior  columns  or 
posterior  nerve-roots  are 
generally  involved. 

(3)  The  posterior  horns  of 
spinal  gray  substance  may 
be  implicated. 


(1)  May  occur  simultaneous 
with  paresis  or  paralysis 
[primary  contracture). 

(2)  May  follow  paralysis  of 
motion  {post-paralytic  con- 
tracture), if  the  lateral  scle- 
rosis is  a  secondary  affection. 

(1)  Bajnd,  and  preceded  by 
motor  paralysis,  if  the  lesion 
be  an  inflammatory  or  trau- 
matic one. 

(2)  Sloiv,  and  not  associated 
with  motor  paralysis,  if  the 
lesion  be  of  a  degenerative 
kind  (progressive  muscular 
atrophy). 

When  complete  paralysis  of 
motion  exists  in  a  limb,  this 
test  cannot  be  employed. 

(1)  Usually  occurs  indejyen- 
dently  of  inotor  impairment. 

(2)  Abnormal  sensory  phe- 
nomena generally  coexist 
with  it. 


Are  apt  to  accompany  symp- 
toms of  vesical  or  rectal 
impairment  (myelitis). 

'  (1)    May  develop   sloivly  or 
rapidly. 


(2)  Are  often  accompanied 
by  inco- ordination  of  move- 
ment, or  trophic  distiirb- 
ances,  or  impairment  of  the 
bladder  or  rectum. 

(3)  Spinal  reflexes  are  apt  to 
be  diminished  or  abolished. 


Let  us  now  examine  some  of  the  symptoms,  which  have  been  already 
referred  to,  more  in  detaiL 

Motor  Paralysis  (of  spinal  origin)  may  assume  one  of  four  varieties : 

(1)  Hemiplegia — where  one  lateral  half  of  the  bodj^  is  affected  with 
motor  paral3'sis. 

(2)  Paraplegia — where  the  lower  half  oi  the  body  is  affected  with 
motor  paralysis. 

(3)  Hemi-paraplegia — where  the  loicer  half  of  one  lateral  half  of 
the  body  is  affected  with  paralysis  of  motion. 

23 


354 


LECTUKES   ON   NERVOUS   DISEASES. 


(4)  Paralysis  of  special  nerve-roots  (spiiuil-nerve  paralysis). 

The  SENSORY  PHENOMENA,  wliich  iiiav  1)6  pro- 
duced by  lesions  of  the  spinal  cord,  or  of  the  posterior 
nerve-roots,  include  the  following: — 

(1)  Pain — usually  of  a  peculiar  kind  (see  loco- 
motor ataxia,  and  the  various  focal  lesions  of  the  cord). 

(2)  Hype7'sesthexia, or  increased  sensibility  of  parts. 

(3)  Numbness,  or  a  sense  of  tingling  (as  if  "tiie 
l)art  were  asleep''). 

(4)  Sense  of  coldness  or  of  heat  in  some  i)art  of 
the  body. 

(5)  A nsesthesia.  or  loss  of  sensibility.  It  may  be 
complete  or  partial  and  be  limited  to  the  aj^precia- 
tion  of  pain,  touch,  or  temperature  by  the  patient. 

(6)  Delayed  sensation  (see  locomotor  ataxia). 

(7)  Formication,  or  a  feeling  likened  to  the 
crawling  of  ants  over  the  bod}'. 

Among  the  remaining  symptoms  which  are  of  value 
in  the  diagnosis  of  spinal  lesions  may  be  mentioned  : — 

(1)  Incoordination  of  muscular  movements. 

(2)  Diminution ,  abolition,  or  increase  of  the  spinal 
reflexes  (see  Section  II   of  this  volume). 

(3)  Abnormal  electro-muscular  reactions  (see 
Section  II). 

(4)  Contracture  of  7nuscles — often  preceded  by 
stiffness  (see  lateral  spinal  sclerosis). 

(5)  Atrophy  of  muscles  (see  poliom3'elitis  and 
prcjgressive  muscular  atrophy). 

(6)  Vaso-motor  phenomena  (see  myelitis,  ataxia, 
etc.). 

(7)  Symptoms  which  are  indicative  of  destruction 
or  irritation  of  some  of  the  special  physiological  cen- 
tres of  the  spinal  cord  (see  focal  lesions  of  the  cord). 

(8)  Tremor  or  some  other  form  of  spasmodic 
movement.  - 

Fig.  67  exhibits  in  a  diagrammatic  way  several 
of  the  above-mentioned  almormal  conditions  which 

Fig.  92.— a  Diagrammatic  .    ,  t,       n  -i    ..  i    i       •  ^ 

Representation  of  the      may  cocxist  as  a  rcsult  oi  an  Unilateral  lesion  OI 

Secondary  Effects  of  a         , ,  -,  i  .  i?    ii  •       i  i        ta    „  -n 

Lesion  of  the  e.ntire  the   dorsal   Segments  OI   the   spinal  cord.     It  will 

^Aft^r'^Erb^y'^'Notl^the  al-  scrvc  to  aid  the  reader  in  mastering  the  statements 

th"'^s7fso%^ry!Z"s^\7s°c-  made  in  subsequent   pages, — chiefly  those  which 

Te::AJ/n/tienTril^n  Tcfcr  to  the  Symptomatology  of  focal  spinal  lesions. 

l"ons\Tlnd8.''"  '"  """'  The  mctliods  which  should  be  followed  in  inves- 


DISEASES   OF   THE   SPINAL   CORD. 


355 


fif/ating  each  of  the  above-metitioned  si/mptoms  (prior  to  a  diagnosis)  have 
been  fully  described  in  Section  II.,  to  which  the  reader  is  referred. 

Before  we  pass  to  the  consideration  of  the  separate  spinal  diseases, 
I  would  call  attention  to  a  carefullj'  prepared  summary  of  the  functions 
of  special  spinal  segments,  which  diflfers  but  slightly  from  one  compiled 
and  tabulated  by  Starr.*  It  should  be  compared  with  the  diagram  and 
table  of  Gowers  (p.  90),  as  each  will  explain  the  other. 


THE  WHITE 
MATTER  OF 
THE  CORD. 


1.  "Anterior  MEDIAN  COLUMN."  {"  Tiirck's 
column" — "  direct  pyramidal  column.") 


.  "Anterior  root-zone.' 


(Anterior    col- 


A  TABLE  SHOWING  THE    ARCHITECTURE  AND  FUNCTIONS  OF  THE  VARIOUS 
COMPONENT  PARTS  OF  A  SPINAL  SEGMENT. 

Motor  fibres  from  the 
"motor  area"  of  the 
cerebral  hemisjjh  ere 
of  the  same  side  (flg.s. 
5  and  29). 

(1)  Fibres  of  associa- 
tion between  ditter- 
ent  segments  of  the 
spinal  cord  (vertical 
in  direction). 

(2)  Motor  fibres  ■jpasHmg 
from  the  cells  of  the 
anterior  horn  of  the 
spinal  gray  matter  in- 
to the  anterior  nerve- 
roots  (horizontal  in 
direction). 

(1)  Associating  fibres 
between  siti'nal  seg- 
ments. 

(2)  Fibres  of  the  sensory 
tract  of  Gowers  (  ?).  ' 

(3)  Vaso-motor fibresl  ?) . 

(1)  Motor  fibres  from 
the  "motor  area"  of 
the  opposite  cerebral 
hemisphere  (vertical 
in  direction). 

(2)  Hbres  passing  from 
the  cells  of  the  col- 
umn of  Clarke  to  form 
the  direct  cerebellar 
column  (horizontal  in 
direction). 

Fibres  passing  from  the 
cells  of  Clarke's  col- 
umn to  the  cerebel- 
lum. The  "vegeta- 
tive-tracV  of  Starr. 

(1)  Sensory  fibres  from 
posterior  hcrve-roots 
to  si)inal  cells  (except 
those  associated  with 
the  "supei  licial"  or 
"skin  reflexes'")  (hori- 
zontal in  direction). 

(2)  Associating  fibres 
between  s]>inal  seg- 
ments (vertical  in  (U- 
rection). 

(3)  Fibres  of  conduc- 
tion of  sensations  of 
touch  and  the  muscu- 
lar sense,  from  the 
arms  and  neck,  up- 
ward (vertical  in  di- 
rection). 

Fibres  of  conduction  of 
sensations  of  touch 
and  the  muscular 
sen.se,  from  the  legs 
and  lower  half  of  the 
trunk,  upward. 


(a)     Un  -  named 
portio7i. 


.  Lateral  COLUMN  (con-  ^b)  ^'■Crossed 
sisting  of  three  subdivi-  <  pyramidal  col- 
sions).  umn." 


(c)  '■'■Direct  cere- 
bellar column." 


4.    "POSTERO-LATERAL  column."      ("-Column 

of  Burdach"— ''posterior  root-zone"  —".fas- 
ciculus ew/(eaiMs" —postero- external  col- 
umn.) 


,    "PO.STERO-MEDIAN    COLUMN.        ("Column 

of  G oil"— ••.fasciculus    gracilis"  —  ••postero- 
iliternal  column.") 


*  Am.  Jour.  Neurol,  and  Psychiatry,  November,  1884. 


356 


LECTUKES   ON   NERVOUS  DISEASES. 


A  TABLE  SHOWING  THE  ARCHITECTURE  AND  FUNCTIONS  OF  THE  VARIOUS 
COMPONENT  PARTS  OF  A  SPINAL  SEGMENT  lco7Uinued). 


r 


f  (1)  Mesial  (/roup  of  ceUs. 
J   (2)  Lateral  groups  in  the 
i      oeiviciil  and  lumbar  en- 

i.     laigeiueuts. 


Presiding  over  flexion  and 
extension  of  the  limbs 
(possessed  by  all  verte- 
brates). 


f  Cells  of  the 
axtekiok 
Horn. 


THE  GRAY      | 

MATTER  OF  J 

THE  CORD.     1 


Cells  OF  THE 
Cextr.vl 

(tKAY 

Matter. 


Cells  of  the 
Posterior 

HORN'S. 


,,,    ,,.,,,  r iio      f Presiding     over     move- 

(1     Middle  group  oiciiWs  nients  of  the  hand  and 

(2)  Cenlral  group  of  cells  J  fl„gers(  peculiar  to  man) 
in  the  cervical  and  lum-  ^  ^^J  ^^^^  ^ct  of  walking 
bar  enlargements.  I     erect. 

Motor  cells,  whose  peculiar  functions  are  not  deter- 
mined. 

Trophic  centres  for  the  motor  nerves  and  the  muscles 
supplied  by  them. 

Motor  incchnnixtn  necessary  to  spinal  automatism  and 
reflex  spinal  action. 

Anterior  part.      Trophic  centres  for  the  skeleton. 

r  (1)  Trophic    centres    for    the    skin, 
Posterior  part.  \       nails,  bladder,  joints. 
L  (2)  Vaso-inotor  centres. 
Automatic  centres  of  a  complex  nature,  and  the  asso- 
ciating fibres  necessary  to  their  peculiar  functions 
(sexual,  vesical,  rectal,  cilio-spinal,  etc). 

Trophic  centres  for  sensory  conducting-tracts. 

Paths  of  conduction  of  sensations  of  pain,  and  tem- 
perature from  all  parts  below. 

Clarke's  column  of  cells  (vesicular  column)  which  are 
apparently  associated  with  the  fibres  of  the  "direct 
cerebellar  column.'' 

Posterior  group  of  cells ;  related  to  sensations  of  all 
kinds. 

The  sensory  mechanism  necessary  to  spinal  automatism 
and  spinal  reflex  action. 

The  size  of  the  multipolar  cells  of  the  anterior  horns  seems  to  depend  upon  two  factors : 
(1)  the  size  of  the  muscle  supplied  by  the  cell,  and  (2)  the  length  of  the  nerve-fibre  which 
connects  the  cell  with  the  muscle  (Spitzka). 


We  are  now  prepared  to  discuss  the  separate  lesions  enumerated  in 
the  table  of  diseases  of  the  spinal  cord.  The  scattered  hints  which  have 
been  already  given  in  a  previous  section  will  possibly  help  us  to  grasp 
the  salient  features  of  each,  and  their  physioloizical  interpretation. 

In  examining  a  case  of  paral^'sis  of  spinal  origin,  the  following  points 
should  be  ascertained  with  great  care : — 

( 1 )  The  area  of  distribution  of  the  paralysis  (be  it  sensory  or  motor 
in  character). 

(2)  The  degree  of  the  paralysis;  by  separately  testing  the  motor 
power  of  different  sets  of  muscles,  and  also  the  skin  for  sensorv  paralysis 
by  means  of  the  aesthesiometer. 

(3)  The  state  of  nutrition  of  the  paralyzed  muscles  (see  pages  which 
treat  of  poliomyelitis  and  progressive  muscular  atrophy). 

(4)  The  electrical  reactions  of  the  paralyzed  muscles;  noting  all 
aibnormal  formulae  and  the  intensity  of  the  current  required  to  produce 
muscular  contraction  (see  section  on  electricitv). 

(5)  The  presence  or  absence  of  rigidity  in  the  paral^-zed  muscles 
(see  pages  which  discuss  sclerosis  of  lateral  columns). 

(6)  The  condition  of  the  superficial  and  deep  sjnnal  reflexes  of  the 
two  sides.     These  have  been  discussed  in  Section  II. 


SCLEKOSIS    OF   THE   ANTERIOR   COLUMNS.  357 

(7)  The  presence  or  absence  of  symptoms  of  incoordination  of 
muscular  movements  (see  locomotoi'  ataxia). 

SCLEROSIS   OF   THE   ANTERIOR   COLUMNS. 

The  anterior  columns  of  the  cord  are  frequently  called  "^/*e  columns 
of  Turck''''  and  ''the  direct  pyramidal  fasciculi.'''' 

The  first  of  these  names  was  given  in  honor  of  a  distinguished 
pioneer  in  pathological  research  relating  to  spinal  lesions.  The  latter  is 
employed  because  the  bundles  which  compose  these  columns  pass  directly 
from  the  hemisphere  of  the  cerebrum  to  the  ultimate  spinal  segments 
without  decussating  in  the  medulla, — the  anterior  pyramids  of  which  they 
help  to  form. 

Several  diagrams  have  been  introduced  in  Section  I  of  this  volume 
to  illustrate  the  formation  of  these  columns;  as  well  as  their  physiologi- 
cal association  with  the  motor  bundles  of  the  opposite  lateral  column  of 
the  cord  (see  Figs.  29  and  32). 

Morbid  Anatomy. — Sclerosis  of  these  bundles  of  nerve  fibres  usually 
coexists  with  similar  changes  in  those  which  compose  a  part  of  the  lateral 
column  of  the  cord, — the  so-called  ''  crossed  pyramidal  fasciculi."  It  may 
occasionally  exist  as  an  independent  lesion;  but  it  usually  follows  the 
development  of  some  brain  or  cord  lesion  and  travels  downward.  It  is 
then  unilateral.  The  symptoms  which  are  peculiarly  characteristic  of 
its  development  are  unknown.  Its  existence  is  to  be  inferred  when 
secondary  sclerosis  of  the  postero-lateral  columns  is  manifested  by 
symptoms  which  are  clinically  well  determined.  The  pathological  changes 
of  sclerosis  of  the  cord  do  not  differ  from  those  of  that  condition  else- 
where. They  have  been  described  in  the  preceding  chapter,  in  connection 
with  the  brain. 

The  discovery,  made  by  Flechsig,  that  the  relative  projjoriion  of  the 
direct  and  decussating  pyramidal  fibres  differs  in  individuals,  helps  us 
to  properly  interpret  those  rare  cases  where  a  lesion  of  the  cerebral 
hemisphere  has  been  known  to  produce  a  hemiplegia  of  the  same  side 
(instead  of  the  opposed  side)  ;  as  well  as  those  cases  of  greater  frequency 
where  a  paresis  of  the  corresponding  side  coexists  with  a  hemiplegia 
of  the  side  opposed  to  the  cerebral  lesion.  In  one  ease  in  sixty,  no 
decussation  of  the  pyramidal  tracts  occurs. 

SCLEROSIS   OF   THE   MOTOR   FIBRES   OF   THE   LATERAL   COLUMN. 

(Lateral  Spi7ral  Sclerosis — Tetanoid  Paraplegia — Spastic 

Paralysis — Sjiasnwdic    Tabes. ) 

Within  the  lateral  columns  of  the  cord,  we  encounter  a  bundle  of 

motor   fibres  which   decussate  anteriorly  in  the  medulla  at   its   lowest 

part.     They  are,  therefoi-e,  associated  with  the  opposite  cerebral  hemis- 


358 


LECTURES   ON   NERVOUS    DISEASES. 


phere.  These  fibres  occupy  only  :i  portion  of  each  lateral  column,  and 
lie  adjacent  to  the  posterior  horn  of  the  spinal  gray  matter.  They  arc 
known  as  the  "  crossed  pyramidal  "  fibres.  They  are  separated  from  the 
periphery  of  the  spinal  cord  (in  some  of  the  spinal  segments,  although 


MOTOR  F/BR£S 
or  JJITTRAI    COLUMN 


AWSCLES 
COfmtouSD  BY 

effCH  SPINffL 
SEGMENT 


CELLS  OF  THE 
\RMrEmOJi  HORNS 
[OF  SUCCESSIVE 

Sfi/MML  SEGMENrS 


Fig.  93. — A  Diagram  designed  by  the  Author  to  show  the  DiSTRiBaTioN  op  the 
"Crossed  Pyramidal  Fibres"  (of  one  side)  to  the  Cells  of  the  Anterior  Horn 
OF  Successive  Spinal  Segments. — Note  that  the  motor  fibres  of  the  lateral  column  can 
act  upon  the  muscles  only  indirectly  (through  the  cells  of  the  anterior  horn) :  also  that  each 
segment  of  the  cord  receives  from  the  lateral  column  certain  fibres  which  put  the  muscles 
associated  with  that  particular  segment  in  the  circuit  of  cerebral  influence  (volition).  In 
this  diagram,  the  circles  represent  groups  of  cells,  and  not  a  single  cell.  Each  red  fibre 
represents  a  bundle  ofjibres  having  similar  termination.  The  blue  lines  represent  bundles 
of  motor  fibres,  which  form  the  anterior  nerve-root  of  successive  spinal  segments  The 
terminal  muscles  (in  red)  represent  the  entire  group  controlled  by  each  spinal  segment, — 
not  individual  muscles.  Figs.  19  and  32  will  help  to  further  interpret  this  diagram,  i'his 
diagram  illustrates  the  reason  why  the  motor  columns  of  the  spinal  cord  grow  smaller  in  size 
as  they  reach  the  terminal  segment. 

not  so  in  all)  by  the  so-called  ''direct  cerebellar  column."  (Fig.  H).) 
The  size  of  this  motor  bundle  decreases  gradually  (by  the  giving  off  of 
fibres  to  the  various  spinal  segments)  from  the  cervical  enlargement  of 
the  cord  till  it  ends  in  the  lumbar  enlargement. 

Morbid  Anatomy. — Sclerosis  of  this  tract  mav  exist  as  a  primarn 
disease ;  and  also  as  a  secondary  result,  occasioned  b}'  the  development 
of  a  lesion  higher  up  in  a  cerebro-spinal  axis. 


SCLEROSIS   OF   MOTOK   FIBRES   OF   LATERAL   COLUMN.  359 

When  the  disease  is  of  the  primsirv  variety,  sclerosis  is  usually 
found  on  both  sides  of  the  cord  in  the  lateral  column.  When  it  is  of  the 
secondar}'  variet}',  the  sclerotic  process  in  the  cord  (if  due  to  a  cerebral 
lesion)  is  usually  detected  in  the  lateral  column  of  one  side  and  tin- 
anterior  column  of  the  opposite  side.  Fig.  32  will  make  the  reason  of  this 
fact  apparent  to  the  reader. 

In  some  cases,  sclerosis  of  the  posterior  columns  and  the  morbid 
changes  of  poliomyelitis  anterior  may  coexist  with  lateral  spinal  sclerosis. 
Whether  this  is  due  to  an  extension  of  the  morbid  process  or  not  is 
as  yet  not  thoroughly  determined. 

Etiology. — Sclerosis  of  this  tract  of  fibres,  when  it  occurs  as  a 
primary  atfection,  is  rarely  encountered  before  the  twentieth  or  after 
the  fiftieth  j'ear  of  age.  It  may  follow  exposure  to  cold  or  dampness 
and  injuries  of  various  kinds.  In  many  cases,  its  causation  is  very 
obscure.     Some  authors  believe   that  it  starts  as  a  transverse  myelitis. 

The  secondary  variety  occurs  as  the  result  of  an 3^  morbid  process 
which  tends  to  cut  otf  the  fibres  of  the  so-called  "  motor  tracts  "  from 
their  trophic  centres  in  the  motor  area  of  the  brain.  It  is  commonly 
known,  therefore,  as  "  secondar}'  degeneration  "  of  the  spinal  cord.  We 
are  apt  to  encounter  this  condition  as  a  sequel  to  anv  form  of  cerebral 
disease  which  affects  the  motor  fibres  or  ''will-tract."  It  ma j'^  also  be 
due  to  any  spinal  lesion  which  has  involved  the  motor  fibres  of  the 
cord  above  the  seat  of  the  sclerosis. 

Secondary  degeneration  of  nerve  fibres  travels,  as  a  rule,  in  the 
direction  of  the  impulses  conveyed  by  the  fibres  affected  (downward  in 
the  motor,  and  upward  in  the  sensory  bundles). 

PRIMARY   LATERAL   SCLEROSIS. 
{^Primary  Spastic  Paraplegia — Tetanoid  Paraplegia.) 

This  condition  is  usually  present  upon  both  sides  of  the  8|)inal  cord. 
It  is  most  frequently  encountered  in  adidts  between  the  agos  of  thirty 
and  fifty,  although  it  may  exist  in  children.  It  seems  to  be  more  fre- 
quent among  males  than  females,  and  to  attack  individuals  in  apparently 
robust  health.  It  has  been  suggested  that  any  excessive  muscular  exer- 
cise or  strain  may  predispose  to  its  development.  Among  children,  this 
form  of  paralysis  may  be  traced,  apijarently,  in  some  instances,  to  an 
injury  received  upon  the  spinal  column,  to  the  head  during  birth,  or  to 
some  congenital  defect  in  the  development  of  the  motor  apparatus. 

In  the  opinion  of  Bramwell,  lateral  sclerosis  of  the  primary  variety 
is  very  rarely  observed.  He  attributes  the  frequency  of  those  cases 
(which  are  usually  considered  as  of  the  primary  type)  to  a  transverse 
myelitis  unassociated  with  disturbances  of  sensation,  and  usually  present 


360  LECTURES   ON   NERVOFS   DISEASES. 

ill  tlu'  dorsal  se<2,inents  of  the  spiiuil  cord.  In  tliis  view  he  is  supported 
i>y  Ley  den. 

Irrespective  of  tlie  relative  freciuency  of  this  condition  as  a  primary 
disease  or  its  etiology,  the  bilateral  character  of  its  symptoms  is  in 
marked  contrast  to  the  unilateral  character  of  the  form  which  is  com- 
monly re<>arde.d  as  secondarj'. 

Symptoms. — In  this  form  of  spinal  sclerosis,  the  patient  is  attaci<^ed 
Ity  a  paresis  of  a  progressive  character.  This  develops  slowly  and 
attacks,  as  a  rule,  the  low^er  limb  of  both  sides  simultaneously.  Subse- 
quently the  upper  limbs  may  exhibit  similar  s^-mptoms.  There  is  in 
almost  every  case  a  marked  increase  of  the  spinal  reflexes.  The  paralyzed 
muscles  tend  to  become  rigid  to  a  greater  or  less  extent  w'hen  sitting,  rising 
or  walking.     This  accounts  for  peculiarities  in  the  gait  of  these  patients. 

Xo  evidences  of  atrophy  in  the  paral3'zed  muscles,  more  than  would 
be  accounted  for  by  disuse,  are  observed.  Sensation  is  preserved  in  the 
artected  limbs,  and  there  are  few  if  any  well-pronounced  clinical  evidences 
of  disturbed  sensory  functions.  Pain  is  infrequent,  there  is  little  numb- 
ness, tingling,  or  other  subjective  phenomena,  and  the  viscera  of  the 
pelvis  are  not  usuall}-  affected,  as  they  are  liable  to  be  in  myelitis. 

The  stiffness  in  the  legs  which  accompanies  the  development  of 
paresis  compels  the  patient  to  use  two  canes  earlj'^  in  the  disease  when 
attempts  at  walking  are  made.  Subsequently  crutches,  and  possibly  an 
attendant,  are  rendered  necessary.  The  patient  moves  with  the  most 
extreme  difficulty.  When  an  advance  step  is  made  the  feet  appear  to  be 
glued  to  the  ground,  and  are  scraped  or  dragged  along  rather  than  lifted. 
The  pelvis  and  the  limb  as  a  whole  is  lifted  in  order  to  allow  of  the  scraping 
of  the  foot  forward,  because  little  if  any  flexion  is  made  at  the  knee. 

The  knees  frequently  tend  to  become  locked  together  during  the  act 
of  walking,  because  the  foot  is  apt  to  cross  its  fellow  as  it  is  brought 
forward.     This  is  an  evidence  of  spasm  of  the  adductor  muscles. 

As  a  rule,  these  patients  are  inclined  to  stand  upon  the  toes,  rather 
than  on  the  entire  sole  of  the  foot,  when  walking. 

Occasionally  the  muscles  of  the  calf  are  affected  with  spasm  during 
attempts  at  walking,  and  the  foot  is  then  suddenly  raised  from  the 
oround  irrespective  of  the  will  of  the  patient  (hopping  gait).  This  pecu- 
liarit}^  in  gait  closely  resembles  that  of  a  horse  when  affiected  with  what 
is  known  as  the  "  string-halt."  Again,  the  patient  may  be  lifted  suddenly 
upon  the  toes  when  endeavoring  to  walk,  by  contraction  of  the  extensor 
muscles  acting  upon  the  foot. 

A  peculiar  attitude  of  the  back  and  chest  is  observed  as  the  patient 
leans  heavily  first  on  one  cane  and  then  on  the  other  in  order  to  raise 
the  weight  of  his  body  by  the  arms.  The  back  is  strongly  arched  and 
the  chest  is  thrown  very  mxich  forward. 


SECONDARY  LATERAL  SCLEROSIS.  361 

Whenever  the  muscles  are  manipulated  they  become  more  or  less 
tense  and  rigid.  This  is  due  to  the  fact  that  the  spinal  reflexes  are  very 
much  exaggerated  in  this  disease. 

The  knee-jerk  is  markedly  intensified  and  an  "ankle-clonus"  can 
generalh^  be  elicited.  Sometimes  a  blow  upon  the  patella-tendon  causes 
a  response  in  the  opposite  limb.  This  is  known  as  "  radiation  of  the 
reflex.''' 

The  superficial  reflexes  are  sometimes  decreased  or  abolished ;  but 
in  exceptional  instances  they  may  be  exaggerated. 

The  tests  emplo\'ed  to  determine  the  condition  of  the  spinal  reflexes 
have  been  already  described  in  the  second  section  of  this  work. 

After  a  lapse  of  several  months  or  3'ears,  these  patients  are  obliged 
to  remain  in  bed  from  an  inability  to  walk.  The  legs  then  tend  to 
remain  stiffly  extended;  and  the  thighs  are  closely  approximated,  as  the 
result  of  spasm  of  the  adductor  muscles.  The  feet  are  usually  inverted. 
Ultimately,  the  upper  extremities  ma}^  become  aff'ected  with  contracture, 
in  which  case  flexion  predominates  over  extension. 

The  electrical  reactions  of  the  aflfected  muscle  are  normal  or  slightly 
decreased.  Those  of  the  nerves  may  be  diminished,  both  to  the  faradaic 
and  galvanic  currents. 

Cerebral  complications  are  rarely  if  ever  developed ;  the  viscera  are 
apparently-  healthy ;  and  the  pelvic  organs  are  not,  as  a  laile,  aftected. 

In  somewhat  rare  instances,  one  leg  alone,  or  one  leg  and  one  arm 
m?^J  be  attacked.  Such  cases  are  to  be  diagnosed  from  hemiplegia  or 
monoplegia  of  cerebral  origin. 

Diagnosis. — This  condition  is  to  be  distinguished  from  the  secondary 
form  of  lateral  sclerosis ;  from  poliomyelitis ;  from  amyotrophic  lateral 
sclerosis ;  and  from  focal  lesions  of  the  spinal  cord.  A  subsequent 
table  (p.  364)  will  make  the  points  of  discrimination  more  apparent  than  a 
verbal  description. 

SECONDARY    LATERAL   SCLEROSIS. 
{Descending  Spinal  Sclerosis.) 

This  morbid  condition  is  due  to  a  degeneration  of  the  motor  fibres 
of  the  cord  from  any  cause  which  tends  to  separate  them  from  their 
trophic  centres  (which  are  situated  within  the  cortical  motor  centres  of 
the  cerebrum).  Whenever  a  nerve  fibre  is  separated  from  its  trophic  cell^ 
it  tends,  with  few  exceptions,  to  degenerate  in  the  direction  of  the 
impulses  which  it  is  designed  to  transmit.  Hence  motor  fibres  usually 
exhibit  under  such  circimistances  a  progressive  degeneration  downward^ 
and  the  sensory  fibres  a  similar  alteration  in  an  upward  direction. 

The  CEREBRAL  LESIONS  wliich  are  liable  to  produce  this  form  of  spinal 
disease  may  att'ect  one  of  the  following  parts:  (1)  those  convolutions  of 
the    brain  which    are  chiefly'  associated   with   motion;    (2)   the  motor 


362 


LECTUEES   ON   NERVOUS   DISEASES. 


bundles  oi'  the  "corona  radnitii "  or  of  the '' internal   eapsule;"  (3)  the 

caudate  nucleus  or  lenticular  nucleus  ;  (4)  the 
crusta  cruris;  (5)  the  motor  fibres  of  the 
pons;  or  ((i)  the  anterior  pyramids  of  the 
medulla,  above  the  point  of  decussation  of 
tiie  pyramidal  li))res.  Figs.  36  and  79  will 
make  this  apparent  to  the  reader. 

Secondary  degeneration  of  the  spinal 
fibres,  which  occurs  after  cerebral  disease, 
tends,  as  a  rule,  to  progress  downward  both 
in  the  column  of  Tiirck  on  the  same  side, 
and  in  the  lateral  column  of  the  opposite 
side  of  the  cord. 

Although,  in  the  majority  of  cases,  this 
results  in  a  bilateral  spinal  lesion,  the  pre- 
ponderance of  the  symptoms  are  due  to  the 
sclerosis  of  the  lateral  columns.  They  are, 
therefore,  most  marked  upon  the  side  of  the 
body  which  is  opposed  to  the  cerebral  hemi- 
sphere primarily  attacked. 

If,  on  the  other  hand,  the  primary  lesion 
is  confined  to  one  side  of  the  cord,  secondary 
sclerosis  of  the  lateral  column  will  occur  only 
below  the  level  of  the  primary  lesion  on  the 
corresponding  side  of  the  cord. 

Finally,  when  a  transverse  spinal  lesion 
which  affects  both  sides  of  the  cord  exists, 
or  when  a  lesion  of  both  cerebral  hemi- 
spheres or  one  which  crosses  the  median  line 
cuts  off  both  motor  tracts,  it  may  induce 
secondary  sclerosis  of  a  descending  charac- 
ter in  l)oth  of  the  lateral  columns.  In  the 
latter  case,  the  symptoms  exhibited  by  the 
patient  during  life  would  be  of  a  markedly 
bilateral  type. 

Secondary  sclerosis  produces,  as  a  rule, 
about  the  same  train  of  symptoms  as  the 
primary  form,  with  the  exception  that  tlie 
symptoms  are  most  marked  upon  one  side  ; 
provided  they  are  not  exclusively  confined 
to  it. 

Symptoms. — In  this  disease,  pai-esis  or 
'h'e'ent\re\en^;i^'ofSinV^^^^^^        parahjsis,   coiitracture    of    muscle,   and    ex- 


Fig.  94. — A  Diagram  designed  to 
Illustrate  the  Secondary  Scle- 
rosis     WHICH      WOULD       follow      A 

Lesion  of  the  Left  Cerebral 
Hemisphere.  (After  Erb.J  Note 
the  involvement  of  the  column  of 
Tiirck  is  seen  on  the  left  side  in 
sections  1,  2,  3,  4,  o  and  6  (where  its 
fibres    end).       That    of  the     crossed 


SECONDAKY  LATERAL  SCLEROSIS. 


363 


agyeration  of  the  tendon  reflexes  are  the  chief  symptoms  which  are  to 
be  expected. 

The  paralysis  or  paresis  precedea  the  de- 
velopment of  contracture.  The  paralytic  symp- 
toms are  usually  of  a  very  marked  character ; 
and  they  may  have  developed  suddenly.  The 
pelvic  organs  are  liable,  moreover,  to  be  atlected. 
The  skin,  hair  and  nails  ma}^  also  exhibit 
trophic  disturbances. 

All  of  these  symptoms  are  usually  observed 
either  upon  one  side  only  ;  or,  if  on  both  sides, 
one  will  be  more  markedly  affected  than  the 
other.  Whenever  the  exciting  lesion  is  of  a 
bilateral  type,  the  symptoms  will  be  identical 
with  those  described  under  the  primary  variety. 

Diagnosis. — This  form  of  sclerosis  is  to  be 
distinguished  chiefly  from  a  chronic  myelitis 
which  involves  one  lateral  half  of  the  spinal  cord 
in  its  anterior  and  lateral  portions  ;  and  also 
from  those  diseases  which  tend  to  produce  a 
gradual  compression  of  the  spinal  cord,  such  as 
meningitis,  tumors,  etc.  It  is  far  more  frequent 
than  the  primary  variety ;  and  cannot,  as  a  rule, 
l>e  confounded  with  it.  Moreover,  the  history  of 
the  case  will  usually  point  toward  some  cerebral 
or  spinal  lesion  as  its  exciting  cause.  A  sub- 
sequent table  will  aid  the  reader  in  making  the 
necessary  discriminations  between  it  and  other 
spinal  lesions  which  might  be  mistaken  for  it. 

Something  has  already  been  said  regarding 
the  discrimination  of  the  primary  and  second- 
ary forms  of  this  disease  from  other  spinal 
affections.  The  chief  diagnostic  points  by  which 
lateral  spinal  sclerosis  can  be  distinguished  from 
all  otlier  spinal  diseases  (jirovided  it  be  itself 
uncomplicated)  are:  (1)  the  development  of 
jiaralysis  with  contractures  and  rigidity  of  the 
muscles ;  (2)  the  absence  of  atrophxj  ;  and  (3) 
the  marked  increase  in  the  tendon  reflexes. 

When  no  cerebral  symptoms  or  those  of  a 
lesi(m  of  the  upper  part  of  the  cord  (bulbar  symptoms)  have  preceded 
the  development  of  the  contractures  and  paresis,  it  is  safe  to  infer  that 
the  primary  variety  exists. 


Fig.  9o. — A  Diagrammatic  Re- 
presentation OF  THE  Cord  in 
Multiple  Spinal  Sclerosis. 
(After  Erb. )  This  condition. 
as  will  be  seen,  affords  a  marked 
contrast  with  systematic  scle- 
rosis shown  in  Figs.  92  and  P4. 


364 


LECTUEES    ON   NERVOUS   DISEASES. 


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INFLAMMATION   OF   CELLS   OF   ANTEKIOR   HORNS.  365 

Prognosis  — Cases  of  apparent  recovery  from  this  affection  have 
been  recorded  ;  and  in  many  instances  a  period  of  indefinite  duration,  in 
which  no  advance  of  the  symptoms  takes  place,  seems  to  be  developed. 
I  believe  that  a  few  cases  may  be  cured  by  proper  treatment,  and  that 
almost  all  can  be  materially  helped  if  seen  suthciently  early. 

When  it  results  fatally,  the  nuclei  of  the  medulla  are  usually  first 
affected,  thus  producing  the  symptoms  of  the  so-called  "  glosso-labio- 
laryngeal  paralysis,"  or  Duchenne's  disease. 

Treatment. — It  is  my  custom  to  administer  large  doses  of  ergot  to 
these  patients  very  early  in  the  disease, — before  the  paresis  or  contract- 
ures become  very  apparent.  This  drug  alone  will  occasionally  arrest 
the  disease,  in  mj'  opinion. 

To  syphilitic  patients  in  the  active  stage,  or  those  who  have  been 
infected  with  that  disease  at  any  time,  I  administer  the  treatment  sug- 
gested on  page  291. 

I  usually  employ  the  galvanic  and  static  currents  to  the  paralj'zed 
muscles  from  the  onset ;  and,  as  a  tonic,  I  am  in  the  habit  of  giving  cod- 
liver  oil  and  quinine.  The  nitrate  of  silver  in  combination  with  the 
extract  of  belladonna  may  prove  of  service.  Hot  water  (as  recom- 
mended on  page  248)  has  helped  some  of  my  cases. 

I  am  satisfied  that  I  have  obtained  marked  and  permanent  improve- 
ment b}"  the  use  of  the  cautery  and  severe  static  sparks  Avhen  applied  on 
each  side  of  the  spinous  process  of  the  vertebrae  and  the  coutractured 
muscles  every  other  day,  or  less  often,  for  several  weeks  consecutively. 

The  spasms  may  be  relieved  by  daily  hypodermic  injections  of 
gr.  Y^o  of  atropine  to  begin  with,  and  gradually  increasing  the  dose. 

The  efficacy  of  static  electricity  (administered  chiefl}'  by  the 
"  spark  ")  in  relieving  contracture  and  spasm  of  muscles  is  now  quite 
well  established  to  mj-  mind.  I  have  had  quite  an  extended  experience 
with  this  agent ;  and  I  know  of  nothing  that  will  give  such  immediate 
relief  to  patients  so  afflicted. 

The  great  disadvantage  which  most  static  machines  labor  under  (in 
the  hands  of  those  who  own  them)  is  their  lack  of  power.  A  machine 
which  gives  but  a  feeble  and  thin  spark  is  practicalh^  useless  for  medical 
purposes.  Personally,  I  cannot  recommend  revolving  plates  of  less  than 
24  inches  m  diameter ;  and  several  such  plates  are  needed  to  generate  the 
quantit}^  which  is  requisite  to  a  satisfactor}^  use  of  the  induction  machine. 

INFLAMMATION   OF   THE   CELLS   OF   THE  ANTERIOR   HORNS. 

(Poliomyelitis  Anterior,  of  Infants  and  Adults — Atro^ohic  Spinal 
Paralysis — Infantile  Paralysis.) 

This  condition  sometimes  coexists  with  lateral  sclerosis.  It  fre- 
quently occurs,  however,  as  an  independent  affection,  especially  during 
childhood. 


366 


LECTUKES  ON  NERVOUS  DISEASES. 


The  cells  of  the  anterior  horns  are  affected  by  an  inflaniinatorv 
process  in  this  disease;  which,  if  snlliciently  severe, leads  to  their  atrophij 
or  dei^truction. 

Morbid  Anatomy. — When  these  cells  become  inflamed,  their  function 
is  at  once  aiifsli'd;  hence  sudden  paralysis  is  developed,  provided  the 
inflammatory  action  be  of  the  acnte  type.  If  the  gray  matter  be  so 
affected  beyond  the  possibility  of  recovery,  acnte  pigmentary  de^renera- 
tion  of  the  cells  so  attacked  apparently  follows.    The  name  ijoliomyelitis 


Fig.  96 — Poliomyelitis  Anterior  (Acute)  followed  by  Extensive  Atrophy,  chiefly  of 
THE  Right  Side.     (From  a  photograph  in  the  possession  of  the  author.) 


(TtoXfOC,  gray,  and  f.iV87Mg,  mari'otc)  expresses  the  seat  of  the  lesion,  as 
well  as  its  inflammatory  character. 

As  a  resnlt  of  inflammatorA'  and  degenerative  changes  within  the  cells 
of  the  anterior  horns,  the  spinal  nerve-fibres  fwhich  serve  to  connect  the 
inflamed  cells  with  the  muscles)  degenerate  as  a  result  of  defective  nutri- 
tion; and  the  muscles  connected  Avith  those  fibres  also  undergo  rapid 
fatty  degeneration  and  atrophy.  The  symptoms  of  this  disease  tend  to 
confirm  the  vicAv  that  the  ganglion-cells  of  the  anterior  horns  preside  not 
only  over  muscular  movement,  but  that  they  also  serve  to  regulate  the 
nutrition  of  the  muscles  connected  with  them  liv  means  of  the  fibres  whic-h 


INFLAMMATION    OF    CELLS   OF   ANTERIOR    HORNS. 


367 


compose  the  anterior  nerve-i'oots.  It  is  believed  b}'  some  observers, 
liowever,  that  some  of  the  cells  found  in  this  locality  have  a  peculiar 
troj)hic  function. 

The  inflammatory  changes  observed  in  the  spinal  cells  during  an 
attack  of  poliomyelitis  must  not  be  confounded  with  a  non-inflammatory 
degeneration  of  the  cells  in  the  anterior  horns.  This  is  probably  the  spinal 
cause  of  "  progressive  muscular  atrophy  "  (in  which  there  is  no  paralysis). 

The  changes  observed  in  poliomj^elitis  anterior  are  commonly  con- 
lined  to  3ifew  spinal  segvientn.     It  is  not  uncommon  for  the  horn  of  one 


Fig.    97. — Back   View   of  Same  Case,   showing   the  so-called   "Wing-scapula"    (es- 
pecially ON  Right  Side)  fkoji  Atrophy  of  the  Muscles. 


side  to  escape  while  the  other  is  seriousl}^  involved.  Whenever  the 
attack  has  been  a  severe  one,  the  anterior  horn  of  the  affected  segments 
will  appear  after  death  to  be  more  or  less  distorted  from  atrophy  of  its 
cells  and  the  development  of  newly  formed  connective-tissue. 

The  form  of  parali/i<if<  which  develops  in  any  given  case  will  be 
modified  b}'  the  spinal  segments  attacked;  and  also  bj^  the  character  of 
the  attack,  whether  unilateral  or  bilateral.  One  of  my  cases  exhibited 
an  attack  confined  to  the  right  horn  of  the  cervical  segments  and  the  left 
horn  of  the  lumbar  segments.     He  had  paralysis  and  extensive  atroph}' 


368 


LECTURES   ON   NERVOUS   DISEASES. 


of  the  right  arm  and  panilysis  of  the  left  leg,  wliicli  passed  away  after  a 
lapse  of  a  few  weeks. 

If  the  inflammatory  process  is  not  sntliciently  severe  to  prevent  the 
recovery  of  the  cells  attacked,  the  spinal  cord  may  exhil)it  no  evidences 
after  death  of  destructive  processes. 

Etiology. — This  disease  is  commonly  described  as  of  three  varieties. 

the  acute,  subacute,  and  clironic.     It  is  more  common  in  children  than 

in  adults,  although  the  chronic  variety  is  less  frequently  observed  during 
childhood  than  the  acute. 


/I 


Fig.   98. — Profile  View  of  same  case,   showing   atrophy   op  Deltoid   Region,   the 
Altered  Position  of  the  Right  Scapula,  and  the  Wasting  of  the  Right  Arm. 


The  infantile  variety  has  been  known  to  follow  exposure  to  cold  or 
dampness,  overfatigue  of  the  muscles,  some  forms  of  blood-poisoning 
(such  as  eruptive  fevers,  diphtheria,  lead-poisoning,  etc.),  dentition,  and 
traumatism.  Some  cases  develop  from  imi)erfectly  understood  causes. 
It  generally  occurs  before  the  second  year, — seldom  later  than  the  seventh 
3'ear.     It  is  most  common  among  boys. 

The  adult  variety  seems  to  be  excited  chiefly  by  exposure  to  cold  or 
dampness  and  overexertion.  Lead-poisoning  is  said  to  sometimes  excite 
it.     Debilitv,  convalescence   from   fevers,  malaria,  pneumonia,  etc.,  are 


INFLAMMATION   OF   CELLS   OF   ANTERIOR   HORNS.  369 

mentioned  by  authors  as  among  its  fixctors  of  causation.  It  ma^'  develop 
between  the  ages  of  twenty  and  fifty  years.  One  of  my  patients  (Figs. 
99  and  100)  was  so  affected  (after  severe  exertion  and  excessive  in- 
dulgence in  alcohol)  from  sleeping  on  the  ground  during  a  summer 
shower.  The  paralysis  in  this  case  attacked  the  muscles  which  were 
fliietly  employed  by  him  in  his  occupation. 

Symptoms. — The  three  forms  of  this  disease  will  be  described 
separately,  as  the}'  should  be  distinguished  at  the  bedside. 

Acute  Form.  {Infantile  Spinal  Paralysis — Acute  Spinal  Paralysis  of 
Adults.) — The  onset  of  this  form  is  usually  marked  by  a  sudden  elevation  of 


Fig.  9P.— Poliomyelitis  Anterior  Ac  n  \,  oc  lki;i:.(.  in  the  Adult  from  Sleeping  on 
Wet  Ground.  (From  a  photograph  in  the  possession  of  the  Author. )  Note  the  extensive 
atrophy  of  deltoid  region,  forearm,  and  hand. 

temperature.  The  febrile  symptoms  may  be  either  continued  or  remittent 
in  type.  The  fever  may  last  from  twenty-four  hours  to  several  days.  It 
is  not  uncommon  to  observe  pains  in  the  limbs,  muscular  twitchings, 
tremors,  convulsions,  delirium,  and  occasionally  a  sense  of  numbness  in 
connection  with  the  stage  of  fever. 

Sudden  paralysis  of  a  marked  character  soon  follows,  and  with  its 
appearance  the  febrile  symptoms  disappear.  The  paralysis  usually  attains 
its  height  at  the  onset. 

The  .seat  and  type  of  the  paralysis  vary  with  the  spinal  segments 
affected  and  with   the  character  of  the  attack, — whether  unilateral  or 

24 


o/U  LECTUKES   ON   NERVOUS   DISEASES. 

bilatenil.  All  the  limbs  may  bo  ulfected  in  some  cases.  (Complete 
pa^'alysiti.)  Again,  it  may  be-  contined  to  one  lateral  half  of  the 
body.  {Hemitplegia.)  When  the  lesion  is  ])ilateral  and  confined  to  the 
dorsal  or  lumbar  segments,  parajjlegia  may  develop.  Finally,  if  the 
lesion  be  unilateral  and  confined  to  the  cervical  or  lumbar  seg- 
ments, monoplegia  may  occur.  1  have  personally  reported  an  uni(pie 
case,  where  the  right  upper  and  left  lower  limb  were  simultaneously 
paralyzed. 

The  paralysis  of  motion  is  usually  quite  complete  at  the  onset.     It  is 
not  accompanied  by  any  disturl)ances  of  the   sensory  function  as  a  rule, 


Fig.  100. — Full  View  of  same  case,  showing  the  Deformity  and  Atrophy  op  Hand. 
(From  a  photograph  in  the  possession  of  the  Author.) 


although  a  slight  numbness  may  be  complained  of  by  the  i)atient.     The 
pelvic  organs  are  not  atif'ected. 

In  infants,  the  existence  of  paralysis  may  be  overlooked.  Sooner  or 
later,  the  nurse  or  mother  ma}'  notice  that  the  child  does  not  move  its 
arm  or  leg.  When  this  disease  is  suspected  during  infanc3%  the  move- 
ments of  the  limbs  should  be  very  carefully  observed.  Nurses  are  often 
unjustly  blamed  by  physicians  as  well  as  parents  for  the  development  of 
paralysis  in  infants  intrusted  to  their  charge.  The  misfortune  is  in 
many  cases  erroneously  attributed  to  some  blow  or  foil  which  the  child 
may  have  received.     The  fever  which  precedes  the  development  of  the 


INFLAMMATION   OF   CELLS   OF   ANTEKIOR   HORNS.  371 

j)aralysis   is,   therefore,  a   ver}'    important   and   valuable    point   in    the 
diagnosis  of  this  affection. 

Soon  after  the  onset  of  the  paralysis,  the  affected  muscles  of  the 
limb  (some  usually  escape)  cease  to  respond  to  the  faradaic  current. 
They  also  contract  slowly  and  with  abnormal  formulse  when  the  galvanic 
current  is  used  (thus  exhibiting  evidences  of  nerve  degeneration  and 
muscular  degeneration.  (Fig.  58.)  Later  on,  they  exhibit  a  marked 
increase  of  galvanic  excitability,  with  abnormal  formula?. 

Whenever  the  cells  are  not  sutticiently  impaired  to  i)roduce  a 
permanent  arrest  of  their  function,  the  paralyzed  muscles  begin  in  a 
short  time  to  show  a  return  of  power.  In  such  a  case,  the  normal  fornmlfe 
of  muscular  reaction  to  galvanism  returns,  and  faradaic  currents  begin 
to  cause  muscular  contraction. 

After  several  weeks  have  elapsed,  signs  of  ati-ojyhy  will  begin  to  be 
apparent  in  those  muscles  whose  cells  have  been  most  seriously  injured. 
In  all  such  cases,  the  muscular  atrophy  is  markedly  progressive  and 
more  or  less  permanent.  If  a  piece  of  such  a  muscle  be  removed  by 
Duchenne's  trocha,  evidences  of  extensive  fatty  degeneration  could  be 
discerned  under  a  microscope.  This  step  is  sometimes  a  valuable  one  in 
making  a  diagnosis  or  a  prognosis. 

This  variety  is  commonly  described  as  "  infantile  spinal  paralysis,''^ 
because  children  are  more  often  affected  than  adults.  Nevertheless,  it 
is  still  encountered  in  adult  life,  but  rarely  in  old  age.  Prevost  and 
Charcot  were  the  first  observers  to  discover  the  exact  morbid  changes 
which  occur  in  the  anterior  horn  in  this  type  of  disease. 

Subacute  Form. — This  is  a  rare  type  of  disease,  and  never  affects 
children.  It  differs  from  the  acute  variet}-  in  the  gradual  onset  of  the 
l)aralysis,  the  total  absence  of  all  cerebral  s3'mptoms,  the  presence  of 
only  slight  febrile  symptoms,  and  the  fact  that  it  attacks  adults 
exclusively.  It  may  closely  resemble  lead-paralysis  and  progressive 
muscular  atrophy. 

Chronic  Form. — A  chronic  tyi)e  of  inflammation  confined  to  the 
anterior  horns  causes  symptoms  which  may  closely  resemble  those  of 
multiple  neuritis  and  ''progressive  muscular  atro[)hy."  It  is  a  com- 
paratively rare  form  of  disease.     It  may  attack  children  or  adults. 

This  condition  may  be  recognized  from  the  other  forms  of  polio- 
myelitis chiefly  by  its  chronicity.  The  presence  of  severe  neuralgic  pains 
and  other  abnormal  sensor}'  phenomena,  which  exist  for  weeks  or  months 
prior  to  the  dcA'clopment  of  atrophic  changes  in  the  muscles,  points 
rather  to  multiple  neuritis.  The  type  of  muscular  atrophy  which  occurs 
in  this  affection  differs  from  that  observed  in  progressive  muscular 
atrophy,  in  th.at  it  affects  entire  groups  of  muscles  simultaneously.  In 
the   latter   disease,   separate  bundles   in  the  affected   muscles  may   be 


372  LECTUKES   ON   NERVOUS   DISEASES. 

destroyed,  while  others  may  remain  iincliaiii^ed.  The  reactions  of  the 
affected  muscles  to  the  faradaic  and  galvanic  currents  are  similar  to 
those  of  the  acute  variety. 

Diagnosis. — Acute  poliomyelitis  in  the  infant  ma\'  be  mistaken  for 
toxic  neuritis^  ijrogreasive  vuiscular  aij^ojjhy,  ricLets,  the  wasting  diaeasea 
of  childhood,  pseudo-hypertrophic  paralysis,  hemiplegia  from  cerebral  or 
spinal  lesions,  and  (during  its  initial  stage)  with  the  exanthemata  or  some 
of  the  injiammatory  disorders. 

In  the  adult,  the  acute  form  might  be  confounded  with  imiltijtle 
neui^ilis,  jjrogressive  muscular  atrophy,  amyotrophic  lateral  sclerosis, 
hemiplegia,  monoplegia,  myelitis,  and  the  subacute  variety  of  polio- 
myelitis. 

It  does  not  seem  to  me  possible  for  the  reader  to  err  in  the  recog- 
nition of  this  atfection,  provided  the  essential  facts  pertaining  to  this 
disease  are  firmly  fixed  in  his  memory. 

It  should  be  remembered  that  the  acute  form  of  the  disease  begins 
with  a  stage  of  febrile  excitement,  which  ceases  in  a  short  time ;  that 
paralysis  develops  suddenly,  and  reaches  its  height  at  once ;  that  the 
paralysis  begins  to  improve  almost  immediately  after  its  appearance ; 
that  atrophy  of  some  of  the  muscles  previously  paralyzed  also  begins 
soon  after  the  attack ;  that  no  cerebral  symptoms  will  have  existed 
previous  to,  during,  after  the  attack ;  and  that  the  child  or  adult  has 
usually  been  in  perfect  health  up  to  the  commencement  of  the  disease. 

The  paralysis  is  at  first  generally  extensive ;  but  it  soon  becomes 
limited  to  a  greater  or  less  extent.  Rare  exceptions  to  this  rule  have 
been  recorded,  however,  where  the  reverse  has  occurred.  Atrojihy  of 
the  muscles  follows  the  paralysis.  There  is  usuall}^  a  diminution  of 
reflex  spinal  irritability.  Bed-sores  do  not  occur,  nor  are  the  bladder 
and  rectum  atfected.     Disturbances  of  sensibility  are  absent,  as  a  rule. 

The  distinctions  between  the  acute,  subacute,  and  chronic  types  of 
poliomyelitis  are  those  of  degree  rather  than  of  kind.  The  respiratory 
muscles  are  never  involved  in  true  spinal  paralysis,  according  to  Seguin. 
In  this  respect  he  draws  a  line  of  distinction  between  the  so-called 
"■acute  ascending  paralysis"  and  poliomyelitis.  To  ray  mind  this 
clinical  distinction  is  questionable. 

From  progressive  Tnuscular  atrophy  acute  poliomyelitis  is  to  be 
distinguished  by  the  rapid  development  of  the  paralysis,  the  febrile 
stage  which  precedes  its  development,  its  appearance  before  the  seventh 
year  of  age,  and  the  fact  that  the  faradaic  current  fails  to  create  a 
response  in  the  paralyzed  muscles ;  whereas  in  progressive  muscular 
atrophy  the  uninvolved  fibres  of  the  affected  muscles  respond  to 
faradaism.  The  insidious  advent  of  progressive  muscular  atrophy  and 
the   effects    of    electric   tests    (p.    189)    would    decide    Itetween    it   and 


INFLAMMATION    OF    CELLS   OF   ANTERIOR   HORNS. 


373 


poliomj'elitis  in  the  Jidult.  Furthermore,  b}'  means  of  Duchenne's 
trochar  (p.  212),  the  fibres  of  the  muscles  attacked  ma}'  be  examined 
microscopically. 

Pseudo-hypertrophic    parahjsis   can   be   easily    distinguished    from 
poliom3'elitis  by  the  absence  of  a  febrile  stage,  the  increase  in  size  of 


Figs  101  and  102  —A  Case  of  Infantile  Paralysis,  with  Involvement  of  the  Medui.- 
LAKV  Nuclei  (From  two  photographs  in  the  possession  of  the  Author).  The  deformity  of 
the  left  side  of  the  patient  and  the  facial  atrophy  of  the  left  side  is  well  shown.  Several  years 
had  elapsed  between  the  date  of  the  attack  and  the  taking  of  the  photographs. 


the  muscles,  the  locality  affected,  the  normal  electro-muscular  phenomena, 
the  characteristic  gait  (p.  164),  the  late  development  of  symptoms  in  the 
extremities,  the  peculiar  curve  of  the  vertebral  column,  and  the  micro- 
scopical examination  of  the  muscles. 

Rickets  never  produce  paralj'sis,  alterations  in  the  normal  electro- 
muscular  reactions,  nor  a  stasje  of  well-marked  fever. 


o<4  LECTUKES   ON    NERVOUS   DISEASES. 

Hemiplegia  of  cerebral  origin  can  be  diagnosed  from  poliomyelitis 
by  the  history  of  the  case,  the  presence  of  symptoms  of  impairment 
of  the  intellect  or  speech,  by  paralysis  of  some  of  the  cranial  nerves, 
the  development  of  hemiplegia  and  lu'mianu'stliesia  upon  the  same 
side  [if  the  lesion  be  non-cortical  (p.  72)],  the  presence  of  normal  electro- 
n:uscular  formuhe,  the  absence  of  a  febrile  stage,  and  abnormalities  in 
the  pupil. 

j\[>jelilis  commonly  causes  more  or  less  trophic  disturbances ;  l)ut  it 
is  ver}'  liable  to  create  s3-mptoms  reteral)le  to  the  genito-urinary  tract 
as  complications,  and  to  present  all  forms  of  combinations  of  motor  and 
sensory  symptoms,  which  do  not  exist  in  poliomyelitis. 

Some  other  points  in  the  differential  diagnosis  of  this  affection  have 
been  given  in  a  table  when  discussing  sclerosis  of  the  lateral  cohnnn  of 
the  cord.     (P.  364). 

The  condition  of  multiple  neuritis  has  been  verj'  frequently  mistaken 
for  poliomyelitis.  There  seems  to  be  little,  if  an}',  doubt  that  many 
cases  reported  in  the  past  by  authors  of  note  as  those  of  poliomyelitis, 
were  improperly  classed. 

The  development  of  al)normal  sensor}*  phenomena,  such  as  pain, 
anaesthesia,  parasthesise,  etc.,  in  connection  with  motor  disturbances  and 
muscular  atroph}"^,  should  always  lead  to  the  suspicion  of  the  existence 
of  multiple  neuritis. 

Prognosis. — In  cases  afflicted  with  poliomyelitis,  partial  or  complete 
recovery  usually  takes  place.  Some  of  the  muscles  may  undergo  per- 
manent atrophy.  Deformities  ma}'  ensue  from  post-paralytic  contracture, 
in  some  cases.  As  a  rule,  the  electro-muscular  i)henomena  return  to  the 
normal  standard  in  the  muscles  which  are  the  least  affected.  The  power 
of  motion  is  regained  with  greater  or  less  rapidity  and  completeness  : 
and  the  reflexes  tend  to  return  to  the  condition  of  health.  If  the  muscles 
continue  to  respond  at  all  to  the  faradaic  current  during  the  height  of 
the  attack,  it  is  safe  to  predict  a  total  recovery.  I  have  never  seen  a 
muscle  undergo  permanent  atrophy  when  it  constantly  preserved  even  a 
trace  of  faradaic  excitability.  If  the  disease  creates  interference  with  the 
action  of  the  respiratory  nerves,  it  is  possible  for  a  fatal  termination  to 
take  place.     Happily,  such  instances  are  uncommon. 

Treatment. — There  exLsts  experimental  as  well  as  clinical  evidence 
to  show  that  a  regeneration  of  the  cord  may  sometimes  take  place  after 
a  serious  injury.  Hence  we  are  justified  in  devoting  particular  care  and 
attention  to  the  medicinal  and  mechanical  treatment  of  the  peripheral 
manifestations  of  spinal  disease  with  the  hope  that  the  cord  itself  may 
be  stimulated  and  eventually  regain  its  functions. 

The  administration  of  large  doses  of  ergot  early  in  the  acute  variety 
of  poliomyelitis  (as  first  suggested  by  Hnnimond)  often  tends  to  check 


INFLAMMATION    OF   CELLS    OF   ANTEKIOK   HORNS.  3/0 

tlie  inflammatory  i^rocess.  Ten  drops  of  the  fluid  extract  may  be  given 
with  safety  three  times  a  day  to  a  six-months-old  infant.  It  should  not 
be  given  after  evidences  of  muscular  atrophy  appear. 

Strychnia  by  the  mouth,  or  by  injection  into  the  paralj'zed  muscles, 
is  sometimes  of  benefit  to  these  subjects  later  in  the  disease.  The  dose 
must  be  graded  to  tlie  age  of  the  patient.  I  never  give  over  one- 
hundredth  of  a  grain  at  a  dose  to  a  child  under  one  year  of  age.  Per- 
sonal ly,  1  prefer  the  hypodermic  method  of  administration. 

Daily  immersion  of  the  limbs  in  hot  salt  ivater  (110°-120'^)  for  thirty 
minutGS,  friction  (made  l)y  the  hand  or  a  rough  towel  several  times  a 
day),  massage,  and  pas.<;ive  movements  all  tend  to  excite  a  determination 
of  blood  to  the  paralyzed  muscles,  and  are  of  great  utility  in  these  cases. 
I  do  not  believe  in  the  use  of  Joimod's  boot,  as  I  have  known  of  serious 
harm  being  done  by  it.  It  is  a  dangerous  instrument  in  the  hands  of 
inexperienced  persons. 

To  adults  I  often  recommend  the  internal  administration  of  hot- 
tvater  drinking.  If  administered  to  children,  a  competent  nurse  must 
supervise  its  use.  I  have  given  the  rules  for  its  administration  in  a 
preceding  section  (p.  248). 

Electricity  is  an  extremely  valuable  adjunct  to  treatment  in  these 
cases.  It  must  be  kept  up  for  a  long  period  of  time,  and  the  parents  or 
the  patient  must  be  prepared  for  slow  results.  When  the  faradaic 
current  fails  to  create  responsive  contractions  of  the  muscles,  the 
galvanic  or  static  current  must  be  substituted  for  it.  The  strength  of 
the  current  must  be  sufficient  to  create  muscular  contractions.  It 
should  not  be  used  oftener  than  on  alternate  da3^s,  as  a  rule.  Months, 
and  even  years,  may  elapse  before  the  muscles  are  brought  back  to  the 
standard  of  health.*  Pieces  of  the  attected  muscles  may  be  removed 
from  time  to  time  (through  the  aid  of  Duchenne's  trochar)  and  examined 
microscopically.  In  this  way  we  can  decide  regarding  the  progress  of 
the  muscular  atrophy.  If  the  disease  is  progressing  favorably,  the 
percentage  of  oil-globules  scattered  throughout  the  muscular  fibres  will 
show  a  decrease. 

During  the  acute  stage,  the  patient  should  be  kept  in  bed.  After  all 
febrile  symptoms  have  disappeared  this  is  not  neces.sary. 

The  tonic  plan  of  treatment — iron,  quinine,  cod-liver  oil,  arsenic, 
phosphorus,  etc. — ^may  be  combined  with  hypodermics  of  strychnia  when 
deemed  necessary.  The  diet  should  be  nutritious  and  adapted  to  easy 
digestion  and  assimilation. 

*One  of  my  cases  made  a  perfect  recovery  under  electrical  treatment  and  massage,  in 
spite  of  the  fact  that  the  lower  limbs  had  been  almost  completely  paralyzed  for  over  three 
months  previous  to  my  examination  of  the  child.  She  moved  about  the  room  by  the  aid 
of  her  hands  only  when  I  made  my  first  examination  of  the  patient. 


376  LECTURES    ON    NEKVOUS    DISEASES. 

AMYOTKOPHIC   LATERAL   SCLEROSIS. 

In  connection  with  two  systenuitic  spinal  conditions  which  have  been 
already  described,  viz.,  lateral  sclerosis  and  changes  in  the  anterior 
horns,  it  may  be  well  to  consider  another  systematic  allection  of  the 
signal  cord  where  the  two  arc  conil)ined.  This  has  been  named  by 
Charcot,  who  first  recognized  the  pathological  changes  which  tended  to 
prodnce  it,  "  amyotrophic  sclerosis."  The  term  "amyotrophic"  (signi- 
fving  an  absence  of  muscular  nutrition)  expresses  well  the  chief  morbid 
change  which  charncterizes  this  form  of  spinal  sclerosis. 

Morbid  Anatomy. — The  lesion  is  not  confined  necessarily  to  the 
spinal  cord,  for  it  tends  to  extend  throughout  the  medulla  oblongata 
and  even  into  the  peduncle  of  the  cerebrum.  Hence  the  nuclei  of  the 
hypoglossal,  spinal  accessory,  and  facial  nerves  are  involved,  as  a  rule, 
late  in  the  disease.  The  changes  in  the  anterior  horns  in  this  disease  are 
apparently  identical  with  those  which  exist  in  connection  with  progres- 
sive muscular  atrophy.  The  morbid  process  seems  to  start  first  in  the 
cervical  enlargement  of  the  spinal  cord  ;  for  that  reason  the  muscles  of 
the  upper  extremity  are  first  attacked. 

From  these  segments  the  sclerotic  and  degenerative  processes  gen- 
erally extend  both  upward  and  downward.  Bands  of  dense,  newly-formed, 
connective  tissue  are  often  detected  between  the  sclerosed  lateral 
columns  and  those  portions  of  the  anterior  horns  which  are  involved. 

In  the  atrophied  muscles,  the  perimysium  undergoes  a  marked 
hyperplasia.  Inflammator}'  changes  are  more  apparent  than  in  pro- 
gressive muscular  atrophy. 

When  the  medulla  becomes  involved,  the  cells  which  constitute  the 
motor  nuclei  within  the  gray  matter  of  the  floor  of  the  fourth  ventricle 
undergo  a  rapid  degeneration. 

The  deformities  of  the  limbs  which  i-esult  from  muscular  contracture 
are  extreme  in  this  type  of  spinal  sclerosis. 

Etiology. — The  causes  which  conduce  to  the  development  of  this 
condition  are  apparently  similar  to  those  mentioned  in  connection  with 
poliomyelitis  and  primary  sclerosis  of  the  lateral  columns.  Exposure  to 
cold  or  dampness  seems  to  be  a  prominent  cause.  In  one  of  my  cases, 
it  developed  after  prolonged  and  intense  mental  anguish  following  the 
death  of  a  child. 

Charcot,  who  has  investigated  this  disease,  divides  its  manifestations 
into  three  distinct  phases.     These  are  as  follow : — 

1.  The  first  stage  is  manifested  only  in  the  muscles  of  the  upper 
extremities.  2.  During  the  second  stage,  the  muscles  of  the  lower 
extremities  are  attacked.  3.  In  the  third  stage,  the  morbid  process 
extends  to  the  medulla  obloimata. 


AMYOTROPHIC   LATERAL   SCLEROSIS. 


377 


Although  tliis  clinical  distinction  is  generally  true,  there  ma^-  be 
exceptional  instances  in  which  the  disease  attacks  the  medulla  first,  and 
gradually  extends  downward.  Again,  cases  in  which  the  disease  first 
attacks  the  lower  limbs  and  gradually  extends  upwai-d,  have  been  reported. 

First  Stage. — The  duration  of  this  stage  varies  from  four  months  to 
a  year.  During  this  time  tremors  of  the  upper  limbs  appear  early,  and 
paresis  or  paralysis  subsequently  develops.  There  is  no  alteration  in 
the  electric  tf^sts  of  the  muscles.  Fibrillar}^  twitchings  are  commonly 
observed  in  the  muscles  of  these  patients. 

An  extensive  form  of  atrophy  follows  the  paralysis,  and  the  muscles 
tend  to  develop  a  state  of  rigidity  and  contracture  which  creates 
permanent  deformities.  The  characteristic  deformity  of  this  disease  is 
chiefly  observed  in  the  hand,  the  wa-ist  and   fingers   being  permanently 


Fig.  103. — Hand  in  Amyotrophic  Lateral  Sclerosis.     (Charcot.) 


flexed  to  a  greater  or  less  extent,  and  more  or  less  rigid.  Fig.  103 
illustrates  this  attitude. 

Sometimes  the  muscles  of  the  neck  and  jaw  are  thrown  into  a  state 
of  spasm,  which  is  more  or  less  persistent.  After  atrophy  has  progressed 
to  a  marked  extent  in  the  forearm,  this  rigidity  of  the  neck  and  jaw 
usually  tends  to  disappear.  Several  months  usually  elapse  between  the 
first  and  second  stages,  during  which  time  the  disease  appears  to  remain 
stationary. 

Second  Stage. — As  this  disease  advances,  after  it  has  apparently 
remained  stationary  for  a  time,  the  muscles  of  the  lower  limbs  begin 
to  exhibit  evidences  of  paralysis,  and,  at  the  same  time,  tonic  or  clonic 
spasms  (or  both  forms)  may  simultaneously  develop.  Gradually  the 
state  of  permanent  rigidity'  or  contracture  appears  in  some  of  the  atfected 
muscles. 


378  LECTURES   ON    NERVOUS   DISEASES. 

The  spinal  reflexes,  chiefly'  the  knee-jerk,  are  very  much  increased, 
and  in  some  eases  an  ankle-clonns  may  be  detected. 

After  a  consideral)le  lui)se  of  time  has  oecnrred,  the  muscles  of  the 
lower  limbs  tend  to  become  less  rigid  and  give  place  to  atrophu  and 
fibrillary  twitchimjs. 

The  2^<^^vi(^  organs  are  not  usually  disturbed,  nor  is  there  any 
tendency  toward  the  development  of  bed-sores  which  are  so  commonly 
observed  in  connection  with  myelitis. 

The  muscular  atrophy  in  the  upper  limbs  increases  to  a  very  marked 
extent  during  this  stage. 

Third  Stage. — In  many  patients  afflicted  with  this  disease,  the 
development  of  ''  bulbar "'  symptoms  are  superadded  to  the  symptoms  of 
the  second  stage. 

When  these  occur  the  disease  has  extended  to  the  medulla,  and  has 
involved  the  nuclei  of  origin  of  the  cranial  nerves  which  arise  from  the 
medulla.  These  nuclei  are  situated  in  the  gray  matter  of  the  fourth 
ventricle.  (Fig.  16.)  In  this  stage,  we  are  liable  to  encounter  evidences 
of  paralj'sis  in  the  muscles  of  the  tongue,  lips,  larynx,  and  pharvnx. 
The  patient  experiences  difficulty  in  articulation,  in  swallowing,  a'nd  in 
controlling  the  escape  of  saliva  from  the  mouth.  During  the  act  of 
swallowing  the  food  is  liable  to  be  expelled  in  part  through  the  nose,  and 
it  is  with  great  difficulty  that  some  patients  are  able  to  get  the  bolus  of 
food  into  the  phar3-nx.  This  distressing  condition  is  commonh"  known 
as  Duchenne's  disease.  Its  physiognomy  is  shown  in  Figs.  108  and 
109. 

Serious  disturl»ances  of  the  circulation  and  respiration  are  apt  to 
occur  during  this  stage  from  paralysis  of  the  pneumogastric  nuclei. 
These  symptoms  ma}-  prove  the  cause  of  death. 

Amyotrophic  lateral  sclerosis  usually  proA'es  fatal  within  two  years 
after  its  initial  symptoms  make  their  appearance. 

Diagnosis. — This  disease  can  hardly  be  confounded  Avith  any  other 
spinal  affection,  in  spite  of  the  fact  that  some  of  its  manifestations 
closely  resemble  those  of  progressive  muscular  atrophy  and  poliomyelitis. 
When  we  review  the  symptoms  of  the  three  we  may  easily  make  the 
necessary'  discrimination.     (See  table  on  p.  .304.) 

From  progressive  muscular  atrophy  this  disease  can  be  distinguished 
by  the  following  facts  :  The  atrophy  follows  the  ]iaralysis  and  attacks 
groups  of  muscles,  rather  than  individual  fibres.  Contractures  develop, 
resulting  in  characteristic  deformities  of  the  limbs.  The  progress  of 
the  disease  is  rapid.  The  legs  are  attacked  soon  after  the  arms.  The 
medulla  becomes  implicated  in  almost  ever}'  case.  The  disease  is  rapidly 
fatal. 

From  poliomyelitis  (adult  variety)  the  diagnosis  is  made  by  the  fact 


PEOGKESSIVE   MITSCULAR   ATROPHY.  379 

that  the  reflexes  are  iinpairod,  but  the  farado-muscular  excitability  not 
decreased.  Moreover,  the  atrophy  is  more  rapid  and  permanent  in  this 
form  of  spinal  sclerosis.  The  contractures  of  muscles  are  conducive  to 
greater  deformity-;  the  medulla  is  implicated;  fibrillations  are  present; 
improvement  in  the  symptoms  is  rare  ;  and  the  disease  is  always  fatal. 

Prognosis. — I  am  not  aware  that  a  case  of  cure  has  ever  been 
reported.  Death  usuall}'  results  from  an  embarrassment  of  the  circu- 
latory and  respiratory  functions,  in  consequence  of  an  extension  of  the 
morbid  changes  to  the  nuclei  of  tlie  medulla.  It  is  uncommon  for  these 
j)atients  to  live  over  two  or  tliree  years. 

Treatment. — Nothing  can  be  said  under  this  head  which  will  aid  the 
reader  in  curing  this  disease.  Its  advent  deprives  the  i)atient  of  all 
liope  of  cure,  and  places  the  fatal  termination  at  no  ver}-  distant  date. 
I  have,  however,  apparently  succeeded,  by  employing  static  sparks  daily 
to  the  spine  and  limbs,  in  greatly  relieving  the  contracture  of  the 
muscles  and  holding  the  progress  of  the  disease  in  checlv  for  man}- 
months. 

PROGRESSIVE    MUSCULAR    ATROPHY. 

The  close  analogy  which  this  disease  bears  in  some  instances  to 
'*  poliom^'elitis  anterior"  in  the  adult  as  regards  its  symptoms  will  help 
to  explain  the  fact  that  such  cases  are  sometimes  erroneouslj-  regarded 
as  a  A-ariety  of  progressive  muscular  atroph3\ 

This  disease  is  essentially  one  of  adult  life,  although  the  so-called 
"  pseudo-hypertrophic  paralysis  "  of  children  bears  some  resemblance  to 
it.  It  affects  males  more  frequently'  than  females,  and  usually  appears 
between  thirty  and  fift}^  years  of  age. 

Morbid  Anatomy. — A  sloiv  degeneration  of  the  ganglion  cells  of  the 
anterior  horns  of  the  spinal  gra^'  matter,  probably-  independent  of 
inflammatory  changes,  exists  in  this  disease.  It  is  one  of  the  most 
chronic  and  incurable  of  all  spinal  affections,  and  is  comparatively 
common.  By  some  authors,  this  disease  is  believed  to  start  in  the 
muscular  tissue,  in  some  instances, — and  possibly  in  all. 

The  t'esse/«  of  the  cord  are  often  abnormally  dilated.  The  arterioles 
may  be  sclerosed,  and  an  inflammatory  exudation  sometimes  surrounds 
the  larger  arterial  trunks. 

The  neuroglia  is  excessively  developed.  Sometimes  the  anterior 
roots  of  the  spinal  nerves  exhibit  atrophic  changes  and  discoloration. 

The  antei'ior  horns  of  gray  matter  are  altered  both  in  their  size  and 
appearance.  The  ganglionic  cells  within  them  are  atrophied  or  com- 
pletely obliterated. 

The  ofeeted  muscles  are  shrunken  and  pale  in  color  to  the  naked 
eye.     The  microscope  reveals  a  disappearance  of  the  transverse  stria.'  in 


380 


LECTURES   ON   NERVOUS   DISEASES. 


the  fibrilla; ;  and  in  those  bundles  most  diseased  all  traces  of  muscular 
tissue  may  have  disappeared.  The  muscular  tissue  has  been  replaced 
by  oil-globules.  This  process  of  muscular  disintegration  does  not 
appear  to  alfect  whole  muscles  at  once  ;  it  seems  to  attack  only  individual 
bundles,  or  even  librillai.  Eventually,  an  entire  muscle  may  thus  Ite 
destroyed,  bundle  by  bundle,  or  libre  bj'  filjre. 

I  am  personally  inclined  to  believe  that  this  disease  is  primarily 
one  of  the  spinal  cord,  and  that  the  muscular  changes  are  a  result  of 
trophic  disturbances  dependent  upon  the  morbid  process  within  tlie 
spinal  oray  matter. 

Etiology. — Among  the  exciting  causes  of  this  affection,  which  have 
been  reported  by  authors  of  note,  may  be  mentioned:  (1)  a  hereditary 


fe_.J_.:f 


Fig.  104.— Fibres  prom   the  Diaphrag.m    in  Fig.  105.— Same  taken  prom  a  Case  of  Pro- 

Health.     (Charcot.)  gressive   Muscular    Atrophy   affecting 

THE  Diaphragm.  (Charcot.)  The  muscular 
fibres  (a)  are  greatly  atrophied  but  preserve 
their  transverse  strise.  The  connective  tissue 
intervals  (b)  are  enlarged. 

tendency;  (2)  excessive  muscular  efforts;  (3)  traumatic  injuries  of 
peripheral  parts  of  the  body;  (4)  lead  poisoning;  (5)  certain  blood 
conditions,  such  as  rheumatism,  measles,  typhoid,  etc. ;  (0)  exposure  to 
cold  and  dampness  ;  (7)  excessive  venery  and  masturbation. 

There  seems  to  be  no  doubt  regarding  an  etiological  relationship 
between  certain  occupations  (demanding  an  excessive  and  continual  use 
of  the  fingers  and  hand)  and  progressive  muscular  atrophy  in  some  of 
the  cases  reported. 

Symptoms. — The  chief  clinical  feature  of  this  disease  is  the  develop- 
ment of  extensive  and  progressive  atrophy  of  certain  muscles. 


PROGRESSIVE   MUSCULAR  ATROPHY.  381 

The  wasting  of  the  muscle  may  not  be  detected  by  the  ])atient  for 
some  time  after  its  onset.  It  is  unattended  with  an^^  symptoms  of 
paralysis,  and  there  are  no  febrile  manifestations  to  mark  its  advent. 

The  patient  usually  first  perceives  that  certain  muscles  are  appar- 
entl}'  wasting,  and  that  some  loss  of  power  has  occurred  in  the  diseased 
part  in  consequence  of  the  diminution  in  size  of  the  affected  muscles. 
This  loss  of  power  is  alwaj's  proportionate  to  the  extent  of  the 
atrophv.  In  this  respect,  this  disease  differs  from  those  spinal  affections 
in  which  paresis  occurs  independent!}'  of  alteration  in  the  muscular 
structure. 

As  a  rule,  progressive  muscular  atrophy  commonly  affects  the  upper 
extremities  first ;  an^l,  in  man}'  cases,  homologous  regions  on  both  sides 
are  successively  attacked. 

Patients  commonly  first  observe  a  wasting  of  the  muscles  of  the 
hand  and  of  the  shoulder.  A  considerable  lapse  of  time  usually  occurs 
before  anj^  evidence  of  atrophic  changes  in  the  lower  limbs  can  be 
detected. 

In  the  hand^  certain  muscular  groups  are  genei'all}-  attacked, — chiefly 
those  of  the  thenar  and  h^pothenar  eminences,  and  the  interossei  muscles. 
These  patients  complain  early  of  more  or  less  stiffness  in  the  fingers 
and  an  inability  to  perform  delicate  manipulation  with  the  hand.  Cold 
tends  to  increase  this  difficult}',  and  warmth  to  diminish  it.  The  ball  of 
the  little  finger  and  tliumb  becomes  very  much  wasted  as  the  disease 
progresses,  and  the  bones  of  the  metacari)us  tend  to  become  unduly 
prominent. 

Sooner  or  later  the  hand  assumes  a  characteristic  deformity  on 
account  of  a  predominance  of  power  in  the  extensors  and  abductors  of 
the  thumb  (the  so-called  "  ape-hand  ").  Marked  atrophy  of  the  interossei, 
combined  with  the  unopposed  action  of  the  lumbricales,  may  give  rise 
to  a  condition  commonly  known  as  the  ^'claw-hand."'  Fig.  106  well 
illustrates  this  deformity. 

Flattening  of  the  palm  is  occasionally  observed  as  the  result  of 
atrophy  of  the  lumbricales. 

When  the  muscles  of  the  shoulder  become  involved,  the  movements 
of  the  arm  are  more  or  less  interfered  with,  and  the  deltoid  region  is 
markedly  flattened.  Atrophy  of  the  scapular  muscles  may  also  occur;  in 
which  case  movements  of  the  arm  are  still  more  seriously  embarrassed. 

In  the  foreaj-m,  the  extensor  muscles  undergo  atrophy  more 
frequently  than  the  flexors.     The  supinators  usually  escape  atrophy. 

As  a  rule,  the  right  hand  is  attacked  before  the  left.  The  muscles 
of  the  scapula  and  trunk  are  not  generally  attacked  until  the  arms 
exhibit  very  marked  atrophic  changes. 

When   the   muscles  of  the   back   or    abdomen   undergo   atrophy,   a 


382 


LECTUEES     OX     NERVOUS     DISEASES. 


cliaracteristic  posture  durin«i  the  erect  attitude  is  developed.     (See  Fi^s. 

54-  and  55.) 

In  very  rare  instances  the  diaplirairm  may  undergo  atrophy,  and 
create  dilliculties  in  respiration. 

The  lower  limbs  are  usually  attacked  late  in  the  disease.  1  have 
observed  one  very  striking  case,  in  which  the  muscles  of  the  thigh  were 
very  extensively  wasted,  in  spite  of  the  fact  that  the  arms  and  trunk 
remained  unaffected.  Generally,  the  flexors  of  the  legs  are  the  first  to 
exhibit  atrophy  when  the  disease  has  extended  to  the  lower  extremities. 

The  electrical  reactions  of  the  muscles  undergoing  atrophy  are 
normal  in  their  formuloe.  They  are,  however,  impaired  (as  is  the  power 
of  the  muscle)  in  a  direct  proportion  to  the  number  of  fibres  which  are 


I 


Fig.  106. — Two  Views  of  the  Hand  op  .\  P.\tient  suffering  prom  Progressivk 
Muscular  Atrophy. 


involved  in  the  ranscle  tested.  The  f:iradaic  current,  as  well  as  the 
galvanic,  will  produce  contractions  of  the  affected  muscle  so  long  as  any 
of  its  individual  fibres  escape  atrophy.  The  "  reaction  of  degeneration  " 
is  not  observed  in  this  disease. 

In  the  early  stages  of  this  disease  the  spinal  reflexes  may  be  more 
or  less  increased,  this  being  the  rule  for  many  of  the  so-called  "  wasting 
diseases."  They  are  of  course  abolished  whenever  all  the  fibres  are 
destroyed,  and  they  tend  to  diminish  proportionately  to  the  extent  of 
the  atroph}'  whenever  it  becomes  established. 

Some  diagnostic  symptoms  are  frequently  observed  in  connection 
with  the  clinical  evidence  of  muscular  atrophy.  Among  these  the 
followin<i  may  be  mentioned  as  prominent  : — 


PROGKESSIVE   MUSCULAR   ATROPHY, 


383 


Fibrillary  Tivilcliiiiija. — Tlicse  aix'  more  apijarent  perhaps  in  this 
disease  than  in  any  other.  Tliey  are  confined  to  the  atroi)hied 
muscles.  Tiiey  consist  in  repeated  and  brief  contractions  of 
individual  [larts  of  the  muscles.  They  are  apt  to  be  most  marked 
Avhen  the  muscles  are  tapped  with  the  linger,  subjected  to  a  current 
of  cold  air,  or  faradized.  Tiiey  are  often  observed  by  the  patient 
while  disrobing  Occasionally,  involuntary  movement  of  the 
fingers,  arm,  or  leg,  m:iy  be  caused  by  them.  It  is  dithcult  to 
detect  them  whenever  the  integument  is  fattv. 


Fig   107. — Progressivh  Muscular  Atrophy  op  all  the  Limbs.     (After  Friedreich  )     The 
age  of  the  patient  was  45  years. 


2.  Dimininhed  Temperature  in  the  Affected  Pat'ts. — A  peculiar  sensi- 
tiveness to  cold  on  the  part  of  tlie  patient  is  perhaps  attributable 
to  this  fact. 

3.  Pains  in  the  muscles  and  in  the  neighboring  joints  are  occasionally 
observed. 

4.  Deformitiefi. — Tliese  are  due  to  shrinking  of  the  muscles  and  the 
unantagonized  action  of  unaffected  muscles.  Tlie  joints  of  the 
fingers  may  become  enlarged. 

5.  The  shin  may  appear  mottled  or  of  a  bluish-red  color  over  the 
wasted  muscles.     The  epidermis  may  become  scaly,  the  nails  may 


384  LECTURES    ON   NERVOUS    DISEASES. 

thicken,  the  growth  of  hair  diiniuisli,  the  secretion  of  perspiration 
become  unnaturally  excessive,  and  erui)tions  may  occasionally  be 
detected. 

6.  Changes  in  the  Fupih. — Tlie  i)upils  may  be  unnaturally  small  on 
one  or  both  sides,  dilate  imperfectly,  and  react  slowly  to  light. 

7.  Bulbar  Symptoms. — These  indicate  an  extension  of  the  spinal 
lesion  to  the  medulla.  Whenever  the  pneumogastrie  nerve 
becomes  involved,  deatli  m;iy  occur  from  a  disturbance  of  the 
heart  and  tlie  function  of  respiration. 

Diagnosis. — This  disease  cannot  well  be  confounded  with  any  other 
spinal  affection,  except  perhaps  one  of  three  forms  of  poliomyelitis  which 
have  been  described.  A  lesion  of  the  ulnar  nerve  might  create  a 
deformit}^  which  could    lie  easily  mistaken  for  a  progressive  muscular 


Fig.  108. — Expression  due  to  Implication  of  the  Nuclei  of  the  Medulla  governing 
THE  Mouth,  Tongue,  and  Throat.      (After  Hammond.) 

atrophy  of  one  extremity'.  Amyotrophic  lateral  sclerosis  and  lead- 
poisoning  present  points  of  difference  which  should  be  readily  recognized. 
The  deformity  of  the  hand  which  ensues  from  progressive  muscular 
atrophy  can  be  distinguished  from  that  due  to  paralysis  of  the  ulnar, 
musculo-spiral  or  median  nerves  by  the  following  points:  (1)  the  groups 
of  muscles  attacked  are  not  supplied  by  one  nerve,  as  a  rule,  but  often 
by  several;  (2)  the  thenar  eminence  is  usually  attacked  first,  then  the 
hypothenar  eminence,  and  finally  the  interossei  muscles  ;  (3)  the  muscles 
of  the  arm  and  shoulder  are  liable  to  be  attacked  simultaneously  with 
those  of  the  hand;  (4)  a  microscopical  examination  of  the  muscles 
alfected  reveals  extensive  fatty  changes;  (5)  the  so-called  '"bird-claw 
hand"  is  produced,  which  differs  from  that  of  any  post-i)aralytic 
deformit}'. 


PKOGKESSIVE  MUSCULAR  ATROPHY. 


385 


The  reader  is  referred  to  page  156  for  information  as  to  other  forms 
of  hand-distortion  or  the  varieties  of  paralysis  exhibited  in  the  hand. 

From  poliomyelitis  (adult  variety^,  this  disease  is  distinguished  by 
the  fact  that  no  paralysis  precedes  the  atrophy.  The  wasting  muscles 
respond  to  faradaism  as  long  as  a  fibre  remains  unaffected.  We  do  not 
have  the  febrile  stage  nor  the  galvanic  "reaction  of  degeneration,"  both 
of  which  are  characteristic  of  poliomyelitis.  The  deformity  of  the 
hand  may  be  identical  in  both  diseases.     For  that  reason  the  history  of 


Fig.  109  —Profile  of  Patient  similarly  affected.     (After  Hammond.) 

the  case  is  very  important,  provided  the  patient  had  not  been  seen  until 
the  hand-deformity  became  well  marked. 

From  amyotrophic  lateral  sclerosis,  the  diagnosis  may  be  made  by 
points  already-  given  on  page  378. 

From  lead-j)oisoning ,  this  disease  is  to  be  told  by  the  fact  that  the 
extensor  muscles  of  the  wrist  and  fingers  are  invariably  paralyzed  by 
lead,  causing  the  so-called  "drop-wrist."  Furthermore,  the  blue-line 
about  the  gums,  the  existence  of  attacks  of  lead-colic,  the  marked 
decrease  in  the  electro-muscular  contractility,  and  the  history  of 
exposure  to  lead,  would  be  wanting  in  a  patient  affected  with  progressive 
muscular  atrophy. 

2S 


m 


LECTUKES   ON  NEKVOUS  DISEASES. 


Progressive  Facial  Atrophy. — I  am  inclined  to  agree  with  Ham- 
mond in  considering  this  rare  condition  as  one  of  the  manifestations  of 
a  condition  closely  allied  to  progressive  muscular  atroph}'.  Hence  it 
may  be  well  to  mention  it  in  the  same  connection,  before  the  indications 
for  treatment  of  the  more  common  malady  is  considered. 

It  is  more  common  in  females  than  in  males.  Its  causes  are 
unknown.  It  affects  adults.  The  pathological  lesion  which  is  associated 
with  atrophic  changes  in  the  facial,  palatine,  and  lingual  muscles  seem  to 
be  a  degeneration  of  some  of  the  cells  which  constitute  the  various 
nuclei  of  the  niedulla. 

The  cuts  introduced  here  show  the  effects  produced  in  a  remark- 
able case  of  facial  hemiatrophy.  The 
face,  tongue,  and  palate  show  atrophic 
changes  upon  the  same  side. 


Fig.  110.- 


-Hemiatrophy  op  the   Face. 
(From  a  photograph.) 


Fig.  111. — Hemiatrophy  of  Tongue  and  Palate. 

(Exhibited  by  the  preceding  case.) 


The  left  side  of  the  face  is  gene- 
rally attacked.     Why  this  is  so  I  am 
nnable  to  explain  satisfactorily  to  my 
own    mind.      It    is    not    an    unvarying 
rule,  however,  since  over  a  dozen  cases  have  been  reported  where  the 
right  side  was  involved. 

It  is  to  be  diagnosed  from  fecial  paralysis  by  its  gradual  onset,  its 
progressive  character,  unimpaired  electro-muscular  reactions,  and  the 
incurability  of  the  aflection. 

Prognosis. — Progressive  muscular  atrophy  is,  as  a  rule,  incurable. 
It  may  run  its  course  very  slowly  in  some  cases,  and  apparently  remain 
stationary  for  long  periods  of  time,  but  there  is  little,  if  any,  hope  of 
permanently  arresting  its  development.  Complete  recovery  is  extremely 
rare.     The  disease  usually  runs  its  course  in  about  five  years,  although 


PEOGKESSIVE   MUSCULAR  ATROPHY.  387 

it  mjly  last  indefinitely.  When  a  well-marked  hereditary  predisposition 
to  the  disease  is  present,  the  prognosis  is  particularly  grave.  This 
disease  nia}^  cause  death  by  attacking  the  muscles  of  deglutition  or 
respiration,  and  also  by  exciting  fatal  complications,  such,  for  example, 
as  bronchitis,  pneumonia,  pulmonary  congestion,  etc. 

Treatment. — Among  the  various  remedial  agents  employed  in  the 
treatment  of  this  disease  may  be  mentioned  the  following  :  galvanism, 
faradaism,  franklinism,  the  actual  cautery-,  phosphorus,  arsenic,  massage, 
inunctions,  warm  baths  at  the  natural  springs,  and  tonics. 

In  employing  electricity,  it  is  advisable  to  use  a  strong  galvanic 
current  or  static  sparks  to  the  spine,  and  to  treat  the  atrophied  muscles 
with  the  faradaic  or  static  current,  or  with  alternating  applications  of 
the  three.  The  polar  method  (p.  186)  is  commonly  employed  in  case  the 
si)ine  is  to  be  stimulated  by  galvanism,  the  neutral  point  being  placed 
at  the  nape  of  the  neck  or  over  the  sternum.  Each  application  should 
not  exceed  ten  minutes.  They  should  not  be  given  oftener  than  on 
alternate  da3's.  The  secondar}^  or  induced  current  is  preferable  to  the 
primary  when  tlie  muscles  are  being  stimulated  by  faradaism.  The 
interruptions  should  be  slow,  and  the  current  strong  enough  to  throw 
each  muscle  into  firm  contractions.  If  the  induced  current  fails  to 
l^roduce  contractions,  then  employ  the  galvanic  or  static  current.  I 
have  seen  very  marked  benefit  follow  a  judicious  use  of  electricity^  in 
these  cases,  but  I  cannot  say  that  I  have  ever  seen  a  case  where  I 
believed  a  perfect  recovery  took  place.  Many  cases  of  reported  cures 
have,  in  mj""  opinion,  been  wrongly  diagnosed,  or  watched  for  too  short 
a  period.  Error  in  diagnosis,  in  the  case  of  this  serious  malad}',  is  not 
uncommon  with  general  practitioners,  and  even  with  some  neurologists. 

When  a  history  of  syphilitic  infection  can  be  discovered,  it  is  well 
to  put  the  patient  upon  specific  treatment  (according  to  the  rules 
suggested  on  page  291). 

I  usiially  advise  moderate  exercise,  friction  of  the  skin,  massage  of 
the  atrophied  parts,  and  a  highly  nutritious  diet  to  these  patients.  The}' 
should  clothe  their  bodies  warmly  in  silk  or  flannels,  and  aA'oid  over- 
fatigue. Arsenic,  phosphorus,  cod-liver  oil,  and  the  bitter  tonics,  are 
often  indicated.  My  experience  with  h3'dropath3^  is  limited.  It  is  claimed 
that  great  benefit  has  been  afforded  b}'  it  in  some  cases  of  this  malad}-. 
The  employment  of  baths  in  warm  natural-spring  waters  affords  relief 
to  the  pains  and  cramps  in  many  cases,  and  cases  of  reported  cures 
have  been  recorded  by  enthusiastic  advocates  of  their  therapeutical 
etiScacy. 

The  employment  of  static  electricity  b}'  the  "  direct"  or  "  indirect 
spark  "  methods  to  the  affected  spinal  segments  and  to  the  atrophied 
muscles  has,  in  my  experience,  so  far  surpassed  galvanism  and  faradaism 


388  LECTURES  ON  NERVOUS  DISEASES. 

in  its  beneficial  effects,  that  I  always  use  it  in  the  treatment  of  these 
cases.  The  machine  employed  for  this  purpose  must,  however,  be  of 
considerable  power.  (See  subseqent  pages  which  treat  of  this  thera- 
peutical agent.) 

PSEUDO-HYPERTROPHIC   PARALYSIS. 

This  term  is  applied  to  a  rare  disease  of  childhood  which  differs 
from  progressive  muscular  atrophy  in  the  following  respects  : — 

(1)  In  the  fact  that  the  muscles  of  the  lower  limbs  are  primarily 
affected  with  atrophic  changes;  (2)  in  that  the  small  muscles  of  the  hand 
are  not  affected;  and  (3)  in  the  circumstance  that  some  muscles  become 
increased  in  size  when  involved.  It  has  been  named  "■  pseudo-hypertro- 
phic  paralysis,"  because  the  increase  in  the  size  of  the  affected  muscles 
is  not  a  genuine  hypertrophy,  but  ratiier  an  increase  in  the  interstitial 
fibrous  tissue  and  fat  of  the  muscles. 

Morbid  Anatomy. — The  question  of  the  exact  pathological  changes 
which  exist  in  tliis  form  of  disease  is  not  yet  decided,  observers  of 
equal  note  having  differed  in  their  examinations  of  the  nerve-centres  of 
patients  so  afflicted.  Some  authors  hold  that  the  disease  is  primarily 
one  of  the  muscles,  while  others  claim  to  have  established  the  fact  that 
the  muscular  changes  are  secondary  to  spinal  lesions.  When  spinal 
changes  exist,  the  motor  and  trophic  cells  of  the  anterior  horns  are 
usually  involved. 

Etiology. — An  hereditary  tendency  to  the  disease  on  the  maternal 
side  seems  to  be  more  clearly  proven  than  the  exact  pathological  pro- 
cesses which  cause  it.  Boys  are  more  frequently  attacked  than  girls, 
and  the  changes  in  the  muscles  usually  commence  l)efoi'e  the  tentli  3'ear. 

Symptoms. — The  symptoms  of  onset  are  very  gi-adual,  and  are 
characterized  by  a  weakness  of  the  legs  and  a  clumsiness  in  walking 
which  is  exhibited  by  frequent  stumbling  and  fiills.  Gradually  the 
patient  assumes  a  characteristic  attitude  and  gait.  These  will  require  a 
separate  description. 

The  attitude  is  very  peculiar.  In  the  standing  posture  the  back  is 
thrown  beyond  the  proper  position,  so  that  a  vertical  line  dropped  from 
the  shoulders  frequently  falls  behind  tlie  sacrum.  (Fig.  112.)  This 
antero-posterior  curvature  entirely  disappears,  however,  when  the  patient 
is  in  the  sitting  posture.  The  feet  are  placed  wide  apart  so  as  to  increase 
the  base  of  support.  The  heels  are  usually  drawn  upward  by  a  con- 
traction of  the  tendo-Achilles.  In  the  effort  to  preserve  the  balance,  the 
arms  are  held  at  the  side  with  the  hands  extended,  and  the  slightest 
touch  may  cause  the  patient  to  fall. 

Anotlier  rem.irkable  feature  of  the  disease  is  the  difficulty  Avhich  is 
experienced  in  rising  from  the  recumbent,  or  even  the  sitting  posture. 


PSEUDO-HYPEKTKOPHIC   PARALYSIS. 


389 


The  sufferer  uses  surroinidiiii:-  objects  us  a  means  of  rising,  drawinir  the 
body  upward  by  tlie  hands.  When  unable  to  reacli  such  assistance  the 
steps  which  are  taken  to  rise  are  thus  described  by  Growers :  "  If  laid, 
for  example,  on  his  back  upon  the  tioor  and  told  to  rise,  he  would  first 
with  great  difficulty  turn  on  his  face;  he  would  next  get  on  his  knees, 
his  head  being  almost  between  his  thighs;  from  this  position  he  would 
gradually  extend  himself,  so  that  he  stands  upon  his  feet  and  hands  with 
all  his  limbs  extended ;  finally  he  would  extend  the  h?p-joint  by  grasping 
the  thigh  with  the  hand,  and  pushing  up  the  bodj',  as   it    were,  b}'  the 


Fig.  112. — Side  View  of  Attitude   of  Pseudo- 
hypertrophic Paralysis.      (Duchenne. ) 


Fig.  113. — Rear  View  of  Attitude  of  Pseudo- 
hypertrophic Paralysis.     (Duchenne.) 


arm/'  This  movement  of  "climbing  up  the  thighs,"  as  it  has  been 
termed,  is  an  indication  of  weakness  in  the  muscles  which  straighten 
the  knee,  and  also  those  which  extend  the  trunk  upon  the  thigh,— the 
extensors  of  the  hip-joint.     (See  Figs.  52  and  53.) 

The  (jait  of  these  iiatients  is  associated  with  an  oscillation  of  the 
body  from  side  to  side,  or  a  waddling  movement.  The  advance  made  at 
each  step  is  very  small,  and  a  difficulty  seems  to  be  experienced  in 
flexing  the  thigh  upon  the  abdomen. 

The  vmscles  of  the  calf  exhibit  early  a  firmness  and  increase  in  size 
which  is  not  proportionate  to  their  motor  force, — as  that  is  far  below 


390  LECTURES   OX   NERVOUS   DISEASES. 

normal.  Soon  they  become  excessively  developed,  as  do  also  those  of 
the  buttock,  while  the  other  muscles  of  the  leg  commonly  grow  smaller 
from  atrophic  changes. 

The  latissimus  dorsi  and  the  lower  j^art  of  the  pectoralis  major 
muscles  exhibit  marked  wasting  in  a  very  large  percentage  of  cases.  In 
some  instances  all  the  striated  muscular  fibres  of  the  body,  including 
even  the  heart,  may  become  afiected. 

The  electric  '.-eactions  of  the  muscles  to  faradaism  are  markedly 
diminished. 

The  spinal  reflexes  are  diminished  in  the  early  stages,  and,  later  on, 
are  abolished.  The  bladder,  rectum,  and  the  sensory  functions  of  the 
skin  are  not  interfered  with  as  a  rule. 

Diagnosis. — The  diagnosis  of  this  affection  cannot  easily  be  con- 
founded with  that  of  any  other  disease.  A  simple  hypertrophy  of 
muscles,  as  a  result  of  increased  vascular  supply,  could  easily  be  dis- 
tinguished from  it  by  the  aid  of  Duchenne's  trochar  and  a  microscope 
The  S3'mptoms  of  muscular  weakness  and  the  characteristic  gait  and 
attitude  would  be  wanting,  moreover,  in  case  the  muscles  had  undergone 
a  genuine  hypertrophy. 

Prognosis. — Although  cases  of  recover}-  have  been  reported,  the 
prognosis  of  this  disease  is  unfavorable.  Life  ma}',  however,  be  pro- 
longed for  many  years,  and  death  usually  occurs  as  the  result  of  some 
intercurrent  affection. 

Treatment. — Authorities   agree   in   the    statement   that   electricity 
forms   the   chief  therapeutical  agent  in  the  treatment  of  this  malady. 
Duchenne   employed   the   faradaic   current   in   the   two   cases   of  cure 
reported  by  him.     They  were  subjected  to  its  influence  from  the  incip-         .^ 
iency  of  the  disease.     Hammond  recommends  the  use  of  galvanism  to         if 
the   spinal   segments  which   are   related   to  the   muscles   affected,  and        ^ 
faradaism   of  the  muscles  themselves  with  as  strong  a  current  as  the 
patient  can  bear.     Massage  and  the  external  use  of  heat  have  proved 
beneficial.     Strj'chnia,  phosphorus,  and  iron  may  assist,  on  account  of 
their  tonic  properties,  in  promoting  the  general  vigor.     Static  electricity 
may  be  substituted  for  faradization  of  the  muscles.     It  is  liest  applied 
in  the  form  of  the   "spark"'  and  the  "static-induced"  current.     (See 
subsequent  chapter.) 

SCLEROSIS   OF    THE   POSTERIOR   COLUMNS.  ' 

{Progressive   Locomotor  Ataxia  —  Tabes  Dorsalis  —  Gray  Degeneration 

of  the  Posterior  Columns.  1 

This  is  an  extremely  common  spinal  affection  of  a  chronic  type.  It 
is  characterized,  when  fully  developed,  b}^  a  difhcult}'  in  walking,  and.  in 
some  cases,  by  an  imperfect  use  of  the  upper  extremities,  defects  in  the 


f 


SCLEROSIS   OF   THE   POSTERIOR   COLUMNS. 


391 


visual  apparatus,  and  marked  disturbauees  of  the  sensory  functions  and 
visceral  reflexes.  There  is  no  actual  loss  of  muscular  power  ;  but,  because 
the  muscles  of  the  limbs  are  imperfectly  coordinated,  the  existence  of 
paralysis  is  often  erroneously  suspected. 

Morbid  Anatomy. — The  spinal  lesion  which  is  characteristic  of  this 
disease  is  confined  chiefly,  but  not  exclusively,  to  the  sensory  columns 
of  the  cord.  (See  Fig.  115.)  For  this  reason  we  should  expect  to 
encounter  during   life  well-marked  disturbances  of  sensation,  and  also 


j'-o' 


Colored. 


Fig.  114. — A  Diagrammatic  Rkprbskntation  op  the  Lesion  of  the  Sensitive  Tracts 
IN  AN  Unilateral  Lesion  of  the  Right  Side,  to  the  Extent  of  the  Colored 
Space.  (After  Erb  )  All  sensitive  tracts  of  corresponding  height,  as  well  as  those  coming 
from  farther  back,  on  the  left  side,  are  interrupted.  On  the  right  side  only  those  are  inter- 
rupted which  enter  by  the  roots  from  1  to  3.  Numbers  0  to  5  represent  the  sensitive  tracts  of 
the  right  side,  entering  with  the  posterior  roots  ;  0'  to  5'  the  same  on  the  left  side. 


incoordination  of  movement.     The  clinical  history  of  this  disease  fully 
sustains  such  conclusion. 

To  the  naked  eye  the  spinal  cord  may,  in  exceptional  cases,  appear 
normal,  although  the  microscope  may  reveal  marked  pathological 
changes.  As  a  rule,  the  posterior  part  of  the  cord  is  more  or  less 
flattened  and  somewhat  narrower  than  normal.  The  consistenc}'  of  this 
part  of  the  cord  is  usually  increased.  The  pia  is  generally  more  or  less 
thickened  and  opaque  over  the  posterior  columns  of  the  cord.  It  may 
also  be   pigmented  and  adherent   both  to  the  cord   itself  and   to  the 


392 


LECTURES   ON    XERVULS   DISEASES. 


arachnoid  and  dura.  Caleareons  plates  ma}'  1)0  found  in  tlie  arachnoid 
and  the  dura. 

The  most  niarlced  clianges  are  usually  observed  in  the  lower  dorsal 
and  upper  luniliar  segments  of  the  cord.  In  these  localities,  the  columns 
of  Burdach  are  usuallj'  most  atfected,  but  in  the  cervical  segments  the 
columns  of  GoU  are  generally  verj-  markedly-  sclerosed. 

The  posterior  nerve-roots  are  usually  more  or  less  atroijhied  as  far 
as  their  ganglia. 

In  exceptional  instances,  sclerotic  changes  have  been  observed  in 

(Cut  Colored.) 


U 


Vx^ 


\\^ 


::  J  f 


Fig.  113. — A  Transverse  Section  op  the  Spinal  Cord  op  an  Ataxic  Patient  in  the 
Upper  Lumbar  Segment.  (Weigert's  staining — 25  diameters.)  Attention  is  called  to  the 
thickening  of  the  coats  and  the  e.^cpanded  lumen  of  the  posterior  spinal  artery':  the  thickened 
coats  and  contracted  lumen  of  the  anterior  spinal  vessels;  the  thickened  coats  and  altered 
lumen  of  the  vessels  in  the  spinal  substance;  the  diflTused  sclerosis  in  the  anterior  and 
lateral  columns  of  the  cord;  the  extensive  sclerosis  and  disappearance  of  the  nerve-fibres 
in  the  postero-internal  column ;  and  the  very  marked  hypertrophy  of  the  meninges.  This 
beautiful  drawing  was  made  by  Dr.  Van  Schaick,  of  New  York,  from  a  section  of  a  typical 
ata.vic  cord. 


the  medulla,  the  pons,  the  corpora  quadrigemina,  and  some  of  the 
cerebral  nerves.  Among  the  latter,  the  nerves  connected  with  the  e^ve 
are  more  commonly  affected. 

A  microscopical  examination  of  the  diseased  area  in  the  conl  shows 
a  disappearance  of  the  nerve-fibres  and  an  excess  of  connective  tissue 


SCLEROSIS  OF  'I'HE  POSTERIOR  COLUMNS.         393 

which  is  poor  in  cells.  The  Avjills  of  the  blood-vessels  are  usually 
luarkcdlj  thickened.  Their  walls  may  also  contain  an  excess  of  nuclei. 
The  medullary  sheath  of  the  nerve-filtr(>s  may  have  undergone  al)sor[)tion. 
leaving  naked  axis-c^dinders. 

Occasionalh',  and  perhaps  more  frecjuently  than  most  authors  seem 
to  believe,  an  increase  of  connective-tissue  may  be  detected  in  the 
vesicular  columns  of  Clarke  and  in  other  parts  of  the  cord  ;  but  the  cells 
of  this  column  are  usuall}'  unaffected. 

Ilespecting  the  exact  nature  of  these  changes  and  the  causes  which 
induce  them,  authorities  of  note  differ.  Some  regard  them  as  inflamma- 
tor}',  others  as  the  result  of  a  primary  non-inflammatory  degeneration 
of  the  nerve-tibres ;  Avhile  a  few  consider  this  disease  as  the  result  of 
Ijrimary  changes  in  the  blood-vessels.  An  inflammation  of  the  pia  and 
arachnoid  ma}'  possibly  act  as  an  exciting  cause,  according  to  some 
published  observations. 

Respecting  the  patholog}'  and  etiology  of  locomotor  ataxia,  my 
friend,  Prof.  William  H.  Porter,  has  lately  called  m}'  attention  to  some 
pathological  facts  which  his  extended  investigations  lead  him  to  regard 
as  of  greater  importance  than  is  usually  attached  to  them.  The  beautiful 
drawing  of  Dr.  Yan  Schaick  (Fig.  115)  is  taken  from  one  of  Dr.  Porter's 
sections,  and  serves  to  illustrate  the  pathological  changes  encountered 
in  locomotor  ataxia. 

Dr.  Porter's  views  may  be  summarized  as  follow  : — 

(1)  That  in  ataxia, there  is  found  after  death  in  every  case  a  thickeiung 
of  the  coatK  of  the  larger  vessels  with  an  alteration  in  their  cdlihrc 
This  he  believes  is  generally  due  to  syphilis. 

(2)  That  the  lumen  of  the  posterior  spinal  artery  is  always  greatly  in 
excess  of  the  normal,  while  that  of  the  anterior  spinal  vessels  is 
generally  below  the  normal  size. 

(3)  That  a  chronic  hypen^mia  of  the  posterior  columns  of  the  cord  is 
thus  primarily  induced. 

(4)  That  excessive  nutrition  induces  an  abnormal    development  of  j 
connective  tissue  in  the  spinal  cord. 

(5)  That  the  complete  organization  of  this  newly-formed  tissue  is 
followed  by  its  contraction,  which,  in  turn,  causes  atrophy  and 
destruction  of  the  nervous  elements  of  the  spinal  cord. 

That  this    observer's  views    may  be  accurately  presented  I   quote 
from  a  communication  received  lately  from  him,  in  which  he  says : — 

Wlien  we  study  carefully  the  anatomical  arrangement  of  the  arterial  system  dis- 
tributed to  the  spinal  cord,  we  find  that  the  anterior  spinal  artery  is  formed  (by  a  branch 
from  each  vertebral  artery)  near  the  junction  of  the  pons  and  medulla.  From  this  point 
it  ]iasses  downward  upon  the  anterior  surface  of  the  spinal  cord,  until  it  reaches  the  third 
or  fourth  cervical  vertebra,  where  it  is  lost  as  a  distinct  and  separate  vessel.     Here  it  forms 


394  LECTURES  OX  NERVOUS  DISEASES. 

a  plexiform  nel-work  with  the  laleral  sj.iual  vessels,  which  constitute  the  source  of  nutritive 
supply  upon  the  anterior  surface  of  the  cord  from  this  point  to  its  termination.  On  the 
posterior  surface  of  the  cord  the  posterior  spinal  artery,  arising  at  nearly  the  same  point, 
descends  as  a  distinct  vessel,  as  far  as  the  second  lumbar  vertebra,  and  then  divides  into 
numerous  branches  to  the  cauda  equina. 

From  this  arrangement  it  is  quite  apparent  that  the  nutritive  supply  of  the  postero- 
internal and  postero-lateral  columns  is  directly  from  this  posterior  spinal  artery,  while  the 
anterior  and  lateral  columns  have  a  more  general  nutritive  supply. 

Physiology  teaches  that  with  a  high  tension  and  increased  rapidity  of  the  blood- 
current,  nutrition  is  diminished;  but  with  a  moderate  or  low  arterial  tension  a  larger 
/  volume  of  blood  comes  in  contact  with  the  tissues,  and  a  longer  period  occurs  in  which  it 
'  is  in  contact  with  the  tissues.  By  this  alternation  in  the  nutritive  supply  the  various 
changes  are  compensated  for,  and  a  normal  standard  is  maintained.  Whenever,  for 
any  reason,  we  have  this  dilatation  unduly  prolonged,  and  the  increased  nutritive 
supply  constantly  above  normal,  we  are  apt  to  have  a  development  of  new  connective- 
tissue  cells  and  basement  substances  (too  often  called  an  intlammation),  without  the 
production  of  serum,  fibrin,  or  pus,  but  with  the  development  of  new  histological  elements. 

With  these  anatomical  and  physiological  Ikcts  clearly  in  mind,  we  are  in  a  position  to 
study  the  vascular  changes  in  locomotor  ataxia,  and  possibly  to  explain  the  reason  for  the 
major  part  of  the  lesion  being  located  in  the  posterior  or  postero-lateral  columns ;  also  the 
more  or  less  general  sclerosis  in  the  superior  portion,  and  throughout  the  cord  as  the 
disease  advances. 

None  seem  to  den}'  the  common  if  not  universal  vascular  changes  in  this  affection.  In 
Cornil  and  Ranvier's  "Pathological  History,"  the  following  statement  is  made:  "A 
peculiarity  of  these  scleroses  consist  in  a  thickening  of  the  walls  of  the  capillaries  and 
small  vessels."  But  thus  far  no  one  of  note  appears  to  have  attached  any  special- 
importance  to  these  vascular  changes  as  a  causative  agent  in  producing  this  disease,  or  as  ' 
an  explanation  for  the  localization  of  the  lesion  in  the  postero-external  and  postero-' 
internal  columns  of  the  spinal  cord. 

The  following  anatomical  conditions  have  been  found  in  all  the  cases  examined  by 
me.  In  some  of  the  cases  examined  the  history  was  of  short  duration,  while  in  others  the 
disease  had  existed  from  eight  to  ten  years.  There  was  a  marked  thickening  of  the 
pia-mater  of  the  cord,  which  is  well  illustrated  in  the  drawing  which  was  kindly  made  for 
me  by  Dr.  George  G.  Van  Schaick.  This  thickened  membrane  was  often  firmly  adherent 
to  the  spinal  cord,  especially  at  the  sclerotic  zone,  and  occasionallv  also  to  the  dura-mater. 

The  vascular  changes  in  all  the  cases  examined  by  me  constituted  the  first  and  most 
apparent  lesion.  It  was  in  the  form  of  a  peculiar  or  hyaline  thickening  of  the  walls  of 
the  smaller  arteries  and  arterioles.  In  some  instances  this  caused  a  marked  thickening  of 
the  wall  with  an  increased  lumen,  while  in  others  a  marked  decrease  in  the  lumen  was 
found. 

A  noticeable  feature  in  all  the  cases  examined  was  the  marked  changes  in  the 
posterior  spinal  artery.  It  was  found  in  every  instance  to  have  its  coats  thickened  and 
its  lumen  expanded.  On  the  other  hand,  the  vessels  of  the  anterior  portion  of  the 
meninges  were  thickened  and  their  lumen  contracted.  [These  va.«cular  changes  are  well 
illustrated  in  the  accompanying  drawing.     (Fig.  115). — Author's  Note.] 

When  the  arterioles  are  thickened  in  this  way  they  undoubtedly  lose  their  power  to 
contract  and  expand  to  meet  the  varying  changes  of  nature,  and  thus  to  regulate  the 
nutritive  supply  to  be  distributed  to  the  various  parts  and  organs  of  the  bodj'.  In  this 
particular  lesion  the  posterior  spinal  artery  being  thickened  and  its  lumen  expanded, 
the  posterior  columns  of  the  cord  receive  an  increased  quantity  of  the  nutritive  material. 


SCLEROSIS    OF   THE   POSTERIOR   COLUMNS.  395 

Ultimately  this  condition  results  in  a  hyiionmtrition,  the  development  of  new  connective 
tissue  corpuscles,  and  new  basement  substance.  According  to  the  law  of  all  newly-formed 
connective  tissue,  contraction  follows  and  thus  causes  a  compression-atrophy,  ami 
ultimately  a  disappearance  of  the  nerve-fibres  in  the  sclerotic  zone. 

Owing  to  the  irregular  thickening  and  dilatation  of  the  posterior  spinal  artery  and 
its  small  branches  (especially  the  latter),  we  find  in  some  the  sclerotic  condition  most 
marked  m  the  posterior  external  columns ;  in  others,  in  the  posterior  internal  or  ihs 
.columns  of  GoU.  in  fact,  m  the  same  cord,  the  lesion  may  be  also  observed  most 
marked  in  one  column  at  one  part,  and  in  another  column  at  another  part ;  but  in  all  cases 
tiie  vessels  immediately  supplying  the  sclerotic  patch  are  invariably  found  thickened  and 
<lilated,  while  in  the  unatiected  portions  they  are  thickened  and  contracted,  or  nearly 
normal  in  appearance. 

In  the  cord  from  which  this  drawing  was  made  the  sclerosis  in  the  inferior  lumbar 
region  was  in  the  posterior  external  columns ;  but  higher  up  in  the  cord  it  was  distinctly 
m  the  columns  of  GoU,  as  represented  m  the  drawing. 

As  there  is  an  increased  rather  than  a  decreased  nutritive  supply,  there  is  no  primary 
change  in  the  ganglion  cells  in  ataxia.  They  only  suffer  whenever  the  new-formed  con- 
nective tissue  becomes  sufficiently  abundant  to  cause  a  compression  of  the  cells.  When 
this  stage  is  reacheil,  some  of  the  cells  may  be  found  in  a  state  of  atrophic  degeneration. 

At  the  anterior  and  lateral  portions  of  the  cord  (the  vascular  supply  being  in  these 
regions  more  general)  the  increase  in  new-formed  or  sclerotic  tissue  is  more  surely 
developed,  forming  either  a  general  or  patchy  sclerosis,  which  is  never  confined  to  a 
distinct  column. 

In  the  medulla  oblongata  this  general  sclerosis  is  apt  to  be  found  throughout  the 
section.  Taking  this  view  of  its  development,  we  may  say  that  the  disease  is  caused  by 
these  vascular  changes.  In  my  opinion,  these  are  primarily  due  to  syphilis  in  a  majority 
of  the  cases,  if  not  in  all.  I  believe  that  the  disease  is  non-inflammatory,  but  one  due  to 
a  prolonged  and  increased  nutritive  supply.  Finally,  it  is  generally  conceded  that  the 
change  in  the   nerve-fibres  and  ganglion  cells  are  secondary,  and  the  result  of  simple 

compression. 

The  insidious  development  and  slow  progress  of  this  disease  argues  strongly  against 
the  lesion  being  inflammatory  m  the  generally-accepted  sense  of  acute  vascular  changes, 
with  an  exudation  of  the  liquor  sanguinis,  and  a  migration  of  the  blood-corpuscles. 

Etiology.— This  disease  may  be  congenital  or  acquired.  If  acquired, 
it  may  follow  traumatisms  of  the  spine,  exposure  to  cold  or  dampness, 
sexual  excesses,  syphilis,  and  some  acute  blood-diseases.  When  con- 
crenital,  it  is  commonly  associated  with  a  syphilitic  diathesis,  although 
not  necessarily  dependent  upon  it. 

The  question  whether  syphilis  can  or  can  not  be  included  among  the 
etiological  factors  of  this  disease  is  still  an  open  one.  There  can  be  no 
question  regarding  the  statement  that  this  disease  is  often  encountered 
in  patients  who  give  a  positive  history  of  syphilitic  infection ;  but  this 
fact  does  not  in  itself  prove  that  the  ataxia  is  a  result  of  the  acquired 
syphilis.  The  coexistence  of  the  two  conditions  may  be  a  mere  coinci- 
dence. Those  who  combat  the  idea  that  a  syphilitic  origin  of  ataxia  is 
ever  present,  advance  the  following  grounds  for  their  belief:  (1)  that  the 
records  from  which  statistics  that  support  the  opposing  view  are  drawn 


39G  LECTURES   OX    XEKVOUS   DISEASES. 

are  very  unreliable  and  often  worthless  ;  (2)  that  the  statistics  of  ataxia 
published  by  ditierent  compilers  show  a  i)ereentage  of  previous  syphilis 
that  fluctuates  between  4  per  cent,  and  90  per  cent,  of  the  collected  cases 
(extremes  which  cannot  be  reconciled);  (3;  that  syijhilitic  lesions  of 
nerve-centres  do  not  tend  to  follow  definite  nerve-tracts  (systematic 
lesions),  and  that  tlie  opposing  view  is  in  opposition  to  all  established 
pathological  data  relating  to  syphdis. 

On  the  other  hand,  it  is  urged  :  (I)  that  late  statistics  (from  which 
all  elements  of  error  have  been  carefully  ex})unged)  show  a  percentage 
of  sj'philis  too  large  to  be  classed  as  a  mere  coincidence;  (2)  that 
specific  treatment  often  relieves  the  ataxic  symptoms  to  a  marked 
degree;  and  (3)  that  our  knowledge  of  syphilitic  processes  in  the  nerve- 
centres  is  as  yet  imi)erfect. 

Personally,  I  am  rather  inclined  to  exclude  the  recognition  of  ataxia 
as  a  syphilitic  disease,  per  se,  in  any  case.  I  have  never  seen  a  cure 
follow  the  most  active  anti-syphilitic  treatment.  1  am,  however,  open  to 
conviction  when  the  disputed  points  regarding  it  are  involved  in  less 
obscurity  than  I  think  they  are  at  the  present  time. 

This  disease  is  more  common  among  males  than  females.  It  is 
usually  encountered  during  middle  life.  It  is  very  rare  during  childhood, 
and  after  the  fiftieth  year. 

Acute  infectious  diseases  are  sometimes  followed  by  the  typical 
spinal  changes  observed  in  this  condition.  It  is  claimed  that  ataxia  may 
also  occur  as  a  result  of  chronic  ergot-poisoning. 

Heredity  can  unquestionably  be  shown  to  exist  in  certain  cases.  In 
one  family  eighteen  cases  of  well-marked  ataxia  were  observed,  accord- 
ing to  Carre. 

Progressive  paralysis  of  the  insane  is  not  infre(iuently  accompanied 
or  preceded  by  the  s^-mptoms  of  this  disease. 

Symptoms. — The  symptoms  of  this  chronic  disease*  extend  over  so 
long  a  period  of  time  (five  to  thirty  years)  that  they  have  been  com- 
monly divided  into  three  stages,  viz.,  those  of  invasion,  incoordination, 
and  the  stage  of  complications. 

The  STAGE  OF  INVASION  is  characterized  by  the  following  sensory 
phenomena:  (1)  pains  of  a  peculiar  character,  which  will  be  described 
later;  (2)  h3'per»sthesia  of  the  skin;  (3)  anjiesthesia  of  the  skin;  (4) 
retarded  conduction  of  sensation;  and  (5)  peculiar  subjective  sensations 
in  the  parts  associated  with  the  affected  spinal  segments.  These  are 
commonly  observed  in  the  lower  extremities,  because  the  sclerosis  is 
confined,  as  a  rule,  to  the  dorsal  and  luml)ar  regions  of  the  cord.  If  tlie 
disease  has  progressed  to  the  cervical  region,  the  upper  extremities  will 

*I   quote  from  my  work  on    "Surgical  Diagnosis"  the  paragraphs  relative  to  the 
symptoms  of  this  disease,  sulijci't  to  some  slight  changes. 


I 


SCLEKOSIS   OF   THE   POSTEEIOR   COLUMNS. 


397 


3l 


be  similarly  afl'ected,  luid  in  addition  the  i)in)ils  will  1)e  contracted  and 
fail  to  respond  to  light.     (P.  120.) 

In  addition  to  the  sensory  phenomena  de- 
scribed, the  spinal  reflexes  (especially  the 
patella  reflex  or  knee-jerk)  will  as  a  rule  be 
diminished  or  abolished. 

The  pains  of  this  disease  are  to  be  dif- 
ferentiated chiefly  from  those  of  rheumatism 
and  neuralgia.  They  are  pathognomonic  of  the 
flrst  and  second  stages  of  ataxia,  and  may 
persist  even  iu  the  third.  They  are  best 
described  as  "  lightning  pains,"  which  are  of  a 
stabbing  or  boring  character  and  extremely 
severe.  They  are  paroxysmal  and  of  momentary 
duration.  Some  patients  compare  them  to  an 
electric  shock,  which  gives  a  sensation  as  if  a 
knife  were  run  into  the  muscles  or  a  joint. 
Unlike  the  pains  of  rheumatism,  with  which 
they  are  often  confounded,  the}"  attack  circum- 
scribed areas  which  are  usualh^  between  joints, 
and  successiA^e  paroxysms  seldom  occur  in  the 
same  spot.  After  the  attack  of  pain  has  sub- 
sided, the  skin  over  the  seat  of  pain  is  extremely 
sensitive  to  the  touch.  They  difler  from  the 
pains  of  neuralgia  in  that  the}'  do  not  follow 
the  course  of  individual  nerve-trunks ;  the}' 
are  not  associated  with  the  so-called  ''  puncta 
dolorosa  "  or  points  of  sensitiveness  to  pressure 
along  the  course  of  the  affected  nerve,  as  is 
the  case  with  neuralgia ;  they  do  not  radiate  in 
the  superficial  area  of  distribution  of  any  special 
nerve-trunk;  they  are  not  commonly  referred  to 
the  skin,  but  to  the  deeper  structures.  Finally, 
they  are  most  frequently  confined  to  the  lower 
extremities  or  to  the  pelvic  organs, — chiefly  the 
bladder  and  rectum. 

These  lightning  pains  are  so  severe  and 
constant  in  some  instances  as  to  induce  suicide  ; 
while  in  less  severe  cases  the  paroxysms  are 
infrequent  and  easily  controlled  by  anodynes. 
They  may  affect  the  stomach  and  be  mistaken 

for  those  of  dyspepsia;  or  the  rectum,  and  be  confounded  with  hivmor- 
rhoidal  disease  ;  or  the  bladder,  and  suggest  the  possible  existence  of  a 


Fig.  116 — A  Diagrammatic  Rep- 
resentation of  THE  Patho- 
logical Lesion  of  the  Cord 
observed  in  locomotor 
Ataxia  (After  Erb.)  Note 
that  the  diseased  portions  are 
represented  as  confined  to  the 
posterior  columns  (those  of  Goll 
and  Burdach)  exchisiveiy. 


398  LECTUllES    ON    XERVOIS    DISEASES. 

calculus  or  cancer  of  the  bladder.  As  the  paroxysms  of  pain  in  some 
cases  not  infrequently  occur  at  loiiijj  intervals  for  months  or  years  belVjre 
the  evidences  of  incoordination  of  movement  appear,  it  is  common  for 
the  specialist  to  meet  with  these  patients  after  an  incorrect  diagnosis 
(usually  of  rheumatism  or  neuralgia)  has  resulted  in  a  long-continued 
and  ineffectual  course  of  medication  on  the  i)art  of  many  medical 
advisers. 

Hypereesfhena  of  the  skin  (especially  at  the  seat  of  ])ain  after  the 
paroxysm  has  passed  away)  is  commonly  met  with  iu  these  cases.  Like 
the  pain,  this  increased  sensitiveness  is  fugitive. 

Anse.-ifhe^ia  of  the  skin  to  the  sense  of  touch,  pain,  or  temperature, 
is  more  or  less  completely  developed  as  the  disease  progresses.  These 
patients  often  experienced,  as  a  result  of  this  anaesthesia,  subjective 
feelings  which  are  peculiar;  for  example,  as  if  the  feet  were  cold  or 
numb;  or  again,  as  if  the  patient  was  standing  upon  feathers  or  wool,  or 
a  pebble  was  in  the  shoe. 

Delayed  Conduction  of  Senmfion. — When  the  sclerosis  of  Burdach's 
column  has  progressed  to  an  extent  sutticient  to  interfere  with,  but  not 
arrest,  the  conduction  of  sensation  to  the  brain  through  the  spinal  cord, 
a  symptom  is  produced  which  is  of  great  clinical  value,  viz.,  the  occur- 
rence of  a  perceptible  interval  of  time  between  the  infliction  of  a  wound 
(a  pin-thrust,  for  example)  or  a  simple  tactile  impulse  and  its  perception 
by  the  patient.  In  making  this  test,  it  is  well  to  have  the  patient  close 
the  eyes  so  as  to  obviate  all  danger  of  seeing  the  test  applied.  I  have 
met  with  one  case  where  the  interval  was  ten  seconds,  and  a  much 
longer  interval  than  that  has  been  recorded. 

The  STAGE  OF   INCOORDINATION    OF    MUSCULAR    MOVEMENTS  followS    after 

a  lapse  of  time,  which  varies  between  the  extreme  limits  of  a  few  months 
and  many  years.  Incoordination  is  usually  first  exhibited  in  the  gait, 
because  the  lesion  is  confined  primarily  to  the  dorsal  and  lumbar  regions 
of  the  cord  in  the  great  majority  of  cases.  When  the  cervical  region 
becomes  involved,  the  upper  extremities  also  exhibit  a  marked  impair- 
ment of  coordinated  movements, — as  manifested,  for  example,  in  the 
efforts  to  button  and  unbutton  the  clothing,  to  carry  the  hand  with 
accuracy  and  rapidity  to  designated  parts  of  the  face  or  body  when 
the  eyes  are  closed,  and  in  writing  letters  with  continuous  curves. 

The  gait  of  ataxic  patients  (although  walking  is  extremely  difficult 
in  some  cases)  is  not  that  of  paralysis.  The  two  should  not  be  con- 
founded with  each  other.  In  this  disease,  the  motor  power  of  any  indi- 
vidual muscle  is  not  impaired,  nor  do  the  limbs  usually  show  any  lack 
of  development.  It  is  only  when  some  act  is  demanded  which  involves 
a  coordination  of  muscular  movement,  or.  in  other  words,  where  several 
muscles    must    be  employed  in  some  special  order,  that    the    ditliculty 


SCLEROSIS   OF   THE   POSTERIOE   COLUMNS. 


399 


becomes    manifest.     Too    much   emphasis    can    not    be    laid    upon    tliis 
distinction  between  incoordination  and  a  loss  of  muscular  power. 

Among  the  early  symptoms  of  incoordination  which  the  patient  ex- 
periences may  be  mentioned  a  ditiiculty  in  performing  feats  of  locomotion 
when  suddenly  called  for,  as  in  hastily  crossing  a  street,  climbing  a  flight 
of  steps,  or  washing  the  face  with  the  eyes  closed.  Under  such  circum- 
stances a  sense  of  insecurity  lirst  dawns  upon  the  ])atient  and  causes 
him  to  avoid  such  acts.     Grradually  he  finds  it  necessary  to  stand  wiili 


Fig.  117. — Extensive  Joint-Changes  in  Connection  with  Locomotor  Ataxia.     (Charcot.) 


the  feet  apart  to  increase  his  base  of  support ;  to  keep  his  eyes  upon  the 
ground  when  walking,  so  as  to  use  the  visual  sense  in  directing  his 
movements,  and  to  employ  canes  to  aid  him  in  preserving  his  balance. 
Such  patients  have  great  difficulty  from  the  first  in  placing  the  feet  upon 
small  objects,  as  in  mounting  into  a  saddle  by  means  of  the  stirrup, 
climbing  ladders,  or  in  getting  upon  a  chair  to  reach  some  object. 

When  incoordination  l)ecomes  still  more  imi)aired,  the  patient  walks 
slowly  and  with  great  deliberation.  The  feet  may  be  suddenly  jerked 
outward,  the  heel  generally  strikes  the  ground  before  the  sole  of  the  foot, 


400  LECTURES   ON    NEKVOUS    DISEASES. 

ciiiisiug  the  peculiar  "  sttim|)ing  gait ;  '"  and  sometimes  the  movements 
of  tlie  legs  are  so  unexpected  that  the  patient  falls  to  the  ground. 

When  the  upjyer  extremities  become  similarly  involved,  the  hand 
cannot  be  rapidly  carried  to  designated  ]K)rtions  of  the  l)ody,  such, 
for  example,  as  the  nose,  mouth,  ear,  shoulder,  etc.,  when  the  patient 
is  instructed  to  do  so,  with  the  usual  accuracy,  provided  that  the  e^-es 
are  closed.  The  clothing  is  buttoned  and  unbuttoned  with  great  ditli- 
cultv.  When  the  patient  is  asked  to  convey  a  glass  of  water  to  the  lips, 
it  is  raised  to  the  proper  level,  held  there  for  an  instant  with  the  eyes 
fixed  upon  it,  and  then  darted  suddenl}^  toward  the  mouth.  The 
handwriting  becomes  markedly  altered  (especially  when  the  eyes  are 
closed),  because  all  continuous  curves  are  made  with  less  ease  than 
straight  lines,  if  not  too  long. 

The  pupils  frequently  show  the  preternatural  contraction  which 
indicates  that  the  cilio-spinal  centre  is  implicated ;  and  the}'  also  fail  to 
properly  respond  to  light,  although  thej^  do  move  when  vision  is  adjusted 
for  a  proper  focus  upon  objects  in  proportion  to  the  distance  of  the 
object  from  the  e3e,  when  within  a  space  of  less  than  twenty  feet. 
This  condition  constitutes  the  so-called  "  Argyll  Robertson's  pupil.*' 
The  tests  for  it  have  been  already  described.     (P.  120.) 

The  various  tests  employed  to  determine  the  ability  of  any  given 
subject  to  coordinate  the  muscles  have  been  quite  full}^  described  in  a 
preceding  chapter.     (P.  1T9.)  r 

In  rare  cases,  the  loss  of  coordination  atfects  the  muscles  which 
move  the  si)ine. 

The  spinal  reflexes  are  greatl}"  altered  in  this  disease,  and  form  an        | 
imptjrtant  factor  in  the  diagnosis.     The  knee-jerk  is  usually  abolished  at         ' 
an  early  stage.     Tickling  the  soles  of  the  feet  generally  fails  to  elicit  the 
so-called  "  plantar  reflex."  W 

In  the  LAST  STAGE,  that  of  complications,  the  bladder,  rectum,  sexual 
organs,  eyes,  bones  and  joints,  skin  and  stomach,  are  liable  to  give  more 
or  less  constant  evidence  of  effects  of  the  spinal  disease  upon  them. 

The  bladder,  which  in  the  earliest  stage  was  affected  by  the  lightning 
pains,  accompanied  often  by  hasty  urination  and  pain  during  the  act, 
graduall}-  exhibits  the  symptoms  of  paresis  in  slow  micturition,  drib- 
bling, or  incontinence.  The  latter  symptom  occurs  as  the  result  of 
retention  of  residual  urine,  which  overflows  at  last  when  the  distended 
bladder  cannot  longer  control  its  escape.  This  condition  should  not  be 
allowed  to  go  unrelieved  from  a  neglect  to  insert  a  catheter.  Finally, 
cystitis  is  often  produced  ;  and.  in  rare  instances,  anaesthesia  of  the 
urethra  is  observed. 

The  rectum,  which  in  the  early  stages  is  frequently  affected  with 
stabbing  pains  and   a   painful   sense   of  excessive  distension,  suffers  a 


SCLEROSIS   OF   THE  POSTERIOR   COLUMNS.  401 

diminution  in  its  reflex  action  later  in  the  disease,  which  induces  consti- 
pation. In  the  final  stage,  paralysis  of  the  organ  may  be  developed,  and 
antesthesia  of  its  mucous  lining  is  observed  in  exceptional  instances. 

The  sexual  organs,  which  in  the  early  stages  are  often  abnormally 
stimulated  (the  sexual  desire  being  increased,  but  the  act  itself  being 
more  or  less  imperfect),  are  very  much  impaired  in  the  advanced  stages 
of  the  disease;  the  sexual  appetite  as  well  as  the  power  of  erection  being 
often  completely  abolished. 

The  organ  of  vision  suffers  late  changes  in  locomotor  ataxia.  The 
peculiar  alterations  of  the  pupil,  first  described  by  Dr.  Argyll  Robertson, 
have  been  already  mentioned.  In  addition,  ptosis,  strabismus,  diplopia, 
and  loss  of  color  perception  are  not  infrequently  recorded  as  compli- 
cations of  this  disease.  Atrophy  of  the  optic  nerve  may  also  be  one  of 
the  results  of  the  first  stage.  Some  authorities  la}''  great  stress  upon 
the  diagnostic  value  of  the  ophthalmoscope  as  a  means  of  detecting  this 
earl}'^  symptom  of  locomotor  ataxia. 

CharcoVs  Disease. — The  hones  and  joints  may  become  disintegrated, 
as  a  late  result  of  this  form  of  spinal  disease,  and  deformities  are  thus 
produced.  Charcot  was  the  first  to  describe  these  conditions,  and  we 
owe  to  him  much  of  our  knowledge  of  the  subject.  The  larger  joints, 
such  as  the  knee,  shoulder,  and  elbow,  are  the  most  liable  to  be  affected. 
Females  are  most  frequently  attacked. 

The  changes  which  occur  are  to  be  differentiated  from  those  of 
chronic  rheumatic  arthritis  by  the  following  peculiarities  :  (1)  that  thej 
are  acute ;  (2)  that  they  involve  large  joints  and  infrequently  the  hip, 
whereas  the  reverse  is  true  of  rheumatic  arthritis ;  (3)  that  effusion  into 
the  affected  joint  is  extensive,  whereas  the  effusion  is  rare  in  rheumatic 
arthritis ;  (4)  that  dislocations  are  spontaneously  produced,  while  they 
are  extremely  rare  in  rheumatic  arthritis ;  (5)  the  changes  are  usually 
painless,  probably  because  analgesia  is  associated  with  them  ;  (6)  some- 
times spontaneous  fractures  occur.  The  most  plausible  explanation  of 
these  bone  changes,  to  my  mind,  is  that  advanced  by  Buzzard,  viz.,  that 
they  are  due  to  changes  within  the  medulla  oblongata. 

Considerable  discussion  has  taken  place  (chiefly  of  late  in  the 
London  Clinical  Society)  relative  to  the  pathological  position  and  rela- 
tions of"  Charcot's  disease."  It  was  claimed  by  some  eminent  authori- 
ties at  that  time  that  the  disease  was  but  a  tj'pe  of  chronic  rheumatic 
arthritis.  With  this  view  I  cannot  agree.  The  points  alreadj-  mentioned' 
seem  to  me  to  confute  this  deduction.  I  have  personally  seen  three 
cases  of  a  typical  character,  and  I  present  a  photograph  of  one.  Each 
of  these  patients  was  afflicted  with  ataxia  before  the  joint  complications. 
Large  joints  (the  knee  in  two  cases  and  the  elbow  and  both  knees  in  one) 
were  attacked.     The  small  joints  were  normal.     The  disorganization  of 

26 


402 


LECTURES   ON   NERVOUS   DISEASES. 


the  affected  joints  was  rapid  and  so  extensive  as  to  result  in  a  "  flail-like '^ 
mobility.  The  morbid  changes  were  absolutely  painless.  The  knee-jerk 
was  absent  in  every  case. 

Buzzard  states  that  in  Charcot's  disease  the  Haversian  canals  are 
dilated  ;    that   the  bones  are  thinned   and  eroded ;    that   the   inorganic 


Figs  IIS  and  119. — Case  of  "Charcot's  Disease"  of  Left  Knbe-Joint  following 
Locomotor  Ataxia.     (From  photographs  in  the  possession  of  the  Author.) 


constituents  of  the  bones  are  diminished  and  replaced  by  fat ;  and  that 
probably  the  specific  gravity  of  the  affected  bones  would  show  a  decrease 
from  that  of  those  unaffected.  In  these  respects,  the  morbid  changes  are 
totally  at  variance  with  those  of  rheumatic  arthritis. 

In  connection  with  the  changes  in  the  bone  and  joints,  gastric  com- 
plications  sometimes   occur.     They   are   characterized   by   attacks   of 


SCLEROSIS    OF   THE   POSTERIOR   COLUMNS. 


403 


vomiting  and  severe  gastralgia.  The^-  are  more  commonly  observed  in 
females  than  in  males. 

Finally,  the  stiii  may  exhibit  trophic  disturbances  in  the  form  of 
herpetic  eruptions  and  bed-sores, 

Eichhorst  has  contrasted  the  percentages  of  the  more  important 
symptoms  of  locomotor  ataxia,  according  to  the  deductions  given  by 
Bernhardt  and  Erb,  in  the  following  table  : — 


1.  Absence  of  Patellar  Tendon  Reflex    .    .    . 

2.  Lancinating  Pains 

3.  Paresis  of  Bladder 

4.  Paralysis  of  Ocular  Muscles 

5.  Myosis 

6.  Rigidity  of  Pupils 

7.  Optic  Atrophy 

8.  Sensory  Disturbances 

9.  Analgesia 

10.  Delayed  Conduction  of  Pain 

11.  Brach-Romberg  Symptom  (swaying  and  totter- 

ing when  eyes  are  closed.) 

12.  Feeling  of  Exhaustion  

13.  Ataxia 

14.  Sexual  Weakness 

15.  Joint  Affection 

16.  Gastric  Crises 


Authority  Quoted. 


BERNHARDT. 

(58  Cases.) 


100.0 
79.5 

74.1 
39.6 
27  2 
48^4 
10.3 
85.9 
31.6 
34.4 


per  cent. 


90.2 
92.0 
94.1 
43.7 
9.6 
5.2 


ERB. 

(56  Cases.) 


98.0  per  cent. 

92.5     •  "   ■ 

81.0 

38.7 

54.0 

50.0 

12.4 

■  69.0 
89.5 

83.5 

97.9 

100.0 

78.5 


It  will  be  observed  that  a  wide  difference  exists  respecting  the 
relative  frequency  of  symptoms  2,  5,  9,  10  and  14  of  the  table.  Future 
investigation  will  probably  tend  to  determine  these  percentages  with 
greater  accurac3\ 

The  patellar  reflex  is  being  quite  extensively  investigated  at  the 
present  time;  It  may  be  absent  in  apparently  healthy  subjects.  It  lias 
been  estimated  that  about  tivo  per  cent,  of  all  adults  fail  to  exhibit  the 
knee-jerk.  Such  subjects  very  frequently  belong,  however,  to  families 
which  exhibit  a  strong  neuropathic  predisposition.  The  knee-jerk  is 
liable  to  disappear  in  advanced  age,  and  in  subjects  suffering  from 
chronic  alcoholism  it  may  occasionally  be  totally  absent.  It  has  been 
suggested  that  an  abnormal  length  of  the  ligamentum  patelloe  may  exist 
in  healtliy  subjects  where  the  knee-jerk  cannot  be  elicited.  Such  a 
condition  would  prevent  the  ligament  being  put  upon  the  requisite 
tension. 

The   effects   of  locomotor  ataxia   upon   the    sexual    functions   are 


404  LECTUKES   ON   NERVOUS   DISEASES. 

usually  manifested  iit  first  In'  an  increase  of  desire,  with  hasty  ejacula- 
tion of  semen.  Later  on,  frequent  seminal  emissions  are  apt  to  occur 
spontaneously,  and  impotency  generall}'  follows.  I  have  observed 
exceptions  to  this  rule,  however,  in  several  cases. 

Respecting  tlie  diagnostic  importance  of  ataxia  as  a  sj-mptom,  the 
fact  should  not  be  lost  sight  of  that  lesions  of  tlie  cerebellum  and  of 
the  "lemniscus  tract  "  within  the  pons  or  medulla  may  create  incoordina- 
tion of  movement,  and  also  that  acute  infectious  diseases  may  occasion- 
ally tend  to  induce  it. 

Diagnosis. — Locomotor  ataxia  may  be,  and  too  fi-equently  is,  mis- 
taken in  its  initial  stage  for  rheumatism  and  neuralgia.  Occasionally 
the  abdominal  crises  of  ataxia  may  cause  the  physician  to  suspect  the 
existence  of  visceral  derangements.  The  points  by  which  the  pains  of 
ataxia  may  be  distinguished  from  those  of  other  afl'ections  of  a  painful 
character  have  been  given  already  (p.  397). 

In  its  second  stage,  locomotor  ataxia  must  be  distinguished  from 
motor  paralysis,  spinal  meningitis,  cerebellar  ataxia,  hysterical  mani- 
festations, chronic  myelitis,  and  multiple  sclerosis  of  the  cord. 

The  symptoms  known  as  those  of  "  CharcoCs  disease "  must  be 
diagnosed  from  those  of  chronic  rheumatic  arthritis. 

Motor  paralysis  can  readily-  be  distinguished  from  ataxia  by  the 
gait  (p.  164)  and  by  testing  the  power  of  individual  muscles.  In  ataxia 
there  is  no  diminution  of  motor  power,  as  ma}'  be  demonstrated  when 
the  muscles  are  subjected  to  proper  tests.  There  is  no  incoordination  of 
movement  when  motor  paralysis  exists.  The  nutrition  of  paralyzed 
muscles  is  generally  impaired.     This  is  not  the  case  in  ataxic  subjects. 

Sjyinal  meningitis  can  be  recognized  bj'  the  existence  of  pain  on 
motion  of  the  spine  and  when  pressure  is  made  over  the  spinous  pro- 
cesses, both  of  which  tests  are  negative  in  ataxia.  Moreover,  febrile 
disturbances  and  more  or  less  motor  paralj-sis  are  liable  to  accompany 
meningitis.  The  reflexes  will  be  normal  or  exaggerated  in  meningitis  ; 
ocular  symptoms  will  not  be  discovered  ;  no  incoordination  of  move- 
ment will  be  developed ;  nor  will  the  clinical  history  of  the  two  diseases 
be  alike. 

Hysterical  ataxia  may  be  recognized  by  the  history  of  the  case  and 
the  condition  of  the  reflexes.  If  the  patient  be  a  male,  h3'steria  can 
generally  be  excluded. 

Cerebellar  lesions  produce  a  peculiar  gait  and  attitude  which  closely 
resembles  that  of  ataxia  in  some  respects.  It  has  been  described  on  a 
previous  page  (p.  165).  Vertigo  is  a  symptom  of  cerebellar  lesions,  and 
gastric  crises  which  are  attended  with  vomiting  are  frequent.  Rotary 
movements  may  be  developed.  The  reader  is  referred  to  page  76  for 
further  information  respecting  cerebellar  lesions. 


SCLEROSIS  OF  THE  POSTEEIOE  COLUMNS.  405 

Chronic  niyelUis  is  to  be  distinguished  from  ataxia  by  peculiar 
combinations  of  sensory  and  motor  plienomena,  which  are  developed 
during  the  progress  of  the  inflammatory  affection ;  by  the  usual  absence 
of  incoordination  of  movement ;  and  by  the  presence  of  spasms,  con- 
tractures, bed-sores,  cystitis,  vesical  paralysis,  febrile  disturbances,  etc. 
The  pupils  are  seldom  affected,  nor  are  tj^pical  ataxic  pains  ever 
encountered  in  myelitis. 

Prognosis. — It  is  my  belief  that  some  cases  of  ataxia  may  be  cured. 
The  majority  are  usually  capable  of  being  greatly  relieved  by  proper 
treatment,  although  some  are  not.  If  it  proves  fatal,  it  generally 
does  so  by  the  aid  of  an  intercurrent  affection.  The  duration  of  the 
disease  can  hardly  be  estimated.  I  have  one  patient  now  under  my  care 
who  gives  a  clear  history  of  ataxic  pains  for  the  past  thirty  j-ears. 
Sometimes  the  second  stage  of  the  disease  is  never  reached.  In  rare 
instances,  the  progress  of  the  disease  may  be  rapid.  In  one  of  my 
cases,  general  paresis  set  in  after  fifteen  j-ears  of  suffering.  He  is  now 
in  an  insane  asjdum. 

Treatment. — In  the  early  stages  of  locomotor  ataxia,  it  is  my  custom 
to  place  the  patient  upon  the  internal  administration  of  hot  water  (p. 
248),  and  to  give  ergot  in  large  doses  (one  drachm  of  the  fluid  extract 
three  times  a  da}').  I  sometimes  administer  the  bromides  of  potash, 
sodium,  or  calcium,  in  place  of  the  ergot.  Three  times  a  week  or  more 
I  usually  employ  heavy  static  sparks  to  the  spine  and  muscles,  and  I 
emplo}'  also  the  actual  cautery  to  the  spine  very  actively  at  intervals. 
In  this  way,  I  have  repeatedly  caused  a  total  arrest  of  the  pains,  which 
had  been  very  frequent  and  severe  up  to  the  date  when  this  treatment 
was  begun.  In  a  few  instances  a  cure  seems  to  have  been  accomplished. 
The  knee-jerk  has  returned,  and  all  symptoms  of  the  disease  have 
disappeared. 

During  the  paroxysms  of  intense  pain,  hypodermic  injections  of 
morphine,  or  the  internal  administration  of  codeine  are  of  service. 

When  a  distinct  syphilitic  history  can  be  obtained  from  the  patient, 
I  giA'e  the  iodides  and  mercurial  baths  as  an  adjunct  to  some  of  the  other 
agents  mentioned. 

When  the  stage  of  incodrdination  has  been  reached,  the  treatment 
must  be  somewhat  modified.  The  bromides  are  of  no  service.  The 
ergot  may  be  continued,  but  the  nitrate  of  silver  in  one-third  grain 
doses  should  be  administered  in  conjunction  with  it  three  times  a  daj-. 
Care  should  be  exercised  against  continuing  tlie  administration  of  this 
agent  long  enough  to  cause  staining  of  the  skin.  The  electrical*  and 
cautery  applications  should  be  regularly  emploj'ed.  Belladonna  is  of 
benefit  when  the  bladder  becomes  affected.  Hammond  recommends  the 
*  My  experience  with  galvanism  has  not  been  as  satisfactory  as  with  the  static  spark. 


406  LECTUEES   ON   NERVOUS   DISEASES. 

hjpodermic  use  of  atvopia  in  doses  of  one  hundred  and  twentieth  of  a 
grain  at  tirst,  tlie  dose  being  gradually'  increased  until  one-thirtieth  of  a 
grain  is  administered. 

The  emploijment  of  crutches  when  walking,  in  order  to  prevent 
excessive  use  of  the  muscles,  has  produced  beneficial  results  in  the 
experience  of  some  authors.  I  am  inclined  to  think  that  the  suggestion 
is  a  good  one.     They  certainly  aid  the  patient  in  walking. 

The  question  of  the  utility  of  stretching  the  sciatic  nerves,  as  first 
suggested  by  Langenbeck  in  1879,  for  the  relief  of  incoordination  and 
the  pains  of  ataxia  is  still  undecided.  Some  remarkable  results  haA^e 
been  accomplished  by  this  procedure,  and  also  some  remarkable  failures. 
The  nerve  is  exposed  by  an  incision  made  above  tlie  popliteal  space. 
The  finger  should  then  be  introduced  beneath  it,  and  the  limb  raised 
by  means  of  the  nerve,  thus  subjecting  it  to  a  tension  sufficient  to 
stretch  it. 

By  means  of  the  different  methods  of  treatment  suggested,  inco- 
ordination of  movement  and  the  parox3'sms  of  pain  ma}'  be  very 
markedly  decreased  in  the  majority  of  cases.  One  patient,  for  example, 
was  lately  placed  under  my  care.  He  came  to  my  office  at  first  in  a 
carriage,  and  was  able  to  ascend  the  steps  of  my  residence  onl}^  b}'  the 
aid  of  two  canes  and  a  body  servant.  In  less  than  three  months  he 
walked  alone  to  my  house  with  only  one  cane,  the  servant  having  been 
dispensed  with.  Another  had  his  pains  (which  were  typical  and  of  daily 
occurrence)  arrested  for  nearly  six  weeks  by  six  applications  of  the 
static  spark. 

Incontinence  of  urine  is  sometimes  a  serious  complication  of  ataxia. 
As  a  rule,  it  is  properly  an  overflow  from  a  highly-distended  bladder, 
rather  than  a  true  incontinence.  It  is  always  well  to  remember  this 
fact,  and  to  introduce  a  catheter  into  the  bladder  at  once  when  this 
symptom  is  presented  l)v  an  ataxic  patient  If  the  bladder  be  found  to 
be  distended  with  retained  urine,  catheterization  should  be  employed 
several  times  each  day  at  regular  intervals,  and  the  bladder  washed  out 
with  care  each  day.  This  can  be  easily  done  by  the  patient  himself  by 
attaching  a  soft-rubber  catheter  to  a  fountain  syringe.  Raising  the 
fountain  fills  the  bladder,  and  lowering  it  siphons  the  fluid  back  into  the 
rubber  bag. 

I  recall  a  case,  which  M^as  sent  to  me  some  three  years  ago,  in  which 
the  patient  (an  ataxic)  had  worn  a  urinal  in  his  trowsers-leg  for  many 
months,  at  the  advice  of  a  physician.  When  I  introduced  a  catheter, 
over  a  quart  of  urine  was  taken  from  the  over-distended  bladder.  The 
treatment  mentioned  above  cured  this  symptom  in  less  than  a  month, 
and  the  patient  was  relieved  of  a  source  of  great  annoyance  and  mortifi- 
cation. 


CENTKAL  MYELITIS.  407 

CENTRAL     MYELITIS. 

In  a  previous  table,  I  have  seen  fit  to  classify  inflammation  of  the 
central  gray  matter  of  the  spinal  cord  as  a  systematic  lesion.  I  am  at 
variance  with  some  authors  in  so  doing.  The  other  varieties  of  myelitis, 
with  the  exception  of  poliomyelitis,  should  un(|uestionably  be  included 
under  the  head  of  focal  spinal  lesions,  because  they  tend  to  spread 
transversely  and  to  involve,  as  they  progress,  one  column  of  the  cord 
after  the  other.  In  this  respect  central  myelitis  seems  to  be  an  excep- 
tion. It  tends  to  spread  chiefly  both  up  and  down  the  cord,  and 
transversel}'  to  a  limited  extent  onfy. 

Morbid  Anatomy. — This  form  of  myelitis  is  a  rare  one.  It  has  been 
known  to  extend  throughout  the  entire  length  of  the  spinal  cord.  It 
may  extend  also  to  the  anterior  or  posterior  horns  of  the  spinal  gray 
matter.     Its  pathologj^  does  not  dift'er  from  that  of  ordinary  myelitis. 

Etiology. — Little  is  positivefy  known  respecting  the  exciting  causes 
of  tills  peculiar  form  of  myelitis,  or  the  physical  condition  which  par- 
ticularly predispose  to  it.  The  remarks  which  I  shall  make  later  relative 
to  the  causes  of  m^-elitis  are  probably  applicable  to  this  condition. 

Symptoms. — These  will  be  modified  (as  might  be  inferred  from  the 
statements  made  in  the  early  pages  of  this  section)  by  the  extent  of  the 
lesion.  The  combination  of  symptoms  which  the  patient  is  liable  to 
present  may  be  an  exceedingly  comjilex  one.  All  the  disorders  of 
sensibilit}'  mentioned  on  a  preceding  page  (p.  354),  as  well  as  parafyses 
of  motility  of  various  types  and  degrees,  with  or  without  contracture, 
may  be  observed.  WhencA'er  the  anterior  horns  are  attacked,  more  or 
less  atrophy  of  muscle  may  accompau}-  or  follow  the  clinical  evidences 
of  impaired  motility. 

The  disease  is  essentially  a  chronic  one  ;  hence,  sufficient  time  is 
afforded  to  carefnllv  observe  and  study  the  development  of  the  A'arious 
symptoms.  The  inflammatory  ju-ocess  may  gradually  extend  to  portions 
of  the  spinal  cord  which  are  diametrically  opposed  in  their  functions. 

As  in  all  inflammatory  processes,  a  stage  of  irritation  first  exists. 
We  observe,  tlierefore,  this  train  of  symptoms  early,  but  usiialfy  for 
only  a  short  duration.  The  effects  of  irritation  upon  the  motor  and 
sensory  apparatus  have  already  been  discussed. 

Whenever  destructive  changes  occur,  a  totally  diflTerent  set  of 
abnormal  nervous  phenomena  from  those  of  the  irritative  stage  are 
pi'oduced. 

Finally,  these  destructive  changes  may  become  an  exciting  cause  of 
a  secondary  degeneration  of  those  bundles  of  nerve-fibres  which  are  cut 
off  by  the  destructiA'e  changes  from  association  with  certain  cells  in  the 
cord  which  act  as  regulators  of  their  nutrition  (trophic  centres). 


408  LECTURES   ON  NERVOUS  DISEASES. 

The  symptoms  of  irritation  may  be  manifested  hy  disturbances  of 
sensibility,  sucli  as  pain,  numbness,  partestiiesite,  byperiesthesia,  etc. ; 
and  also  by  disturbances  of  motility,  sucli  as  niotor  spasm,  exaggerated 
spinal  reflexes,  contracture,  and  changes  in  the  pupils. 

Destruction  of  the  spiiial  gray  matter  may  result  in  a  total  loss  of 
sensation,  marked  paresis  or  paralysis,  marked  atrophy  of  muscles, 
paralysis  of  the  pelvic  organs,  the  development  of  bed-sores  or  other 
atrophic  disturbances  of  the  skin,  and  Robertson's  pupil  (p.  120). 

Diagnosis. — This  disease  cannot  be  confounded  with  any  of  the 
systematic  spinal  diseases  previously  described,  because  a  combination 
of  motor  and  sensory  phenomena  of  an  abnormal  character  is  clinically 
observed. 

Focal  lesions  of  the  cord  closely  resemble  it  in  many  respects. 
They  can  usually  be  recognized,  however,  by  certain  evidences  which  the 
patient  presents  during  the  progress  of  central  myelitis  of  a  progressive 
destruction  of  superimposed  spinal  segments.  When  the  symptoms  of 
focal  lesion  shall  have  been  discussed,  this  distinction  will  be  better 
understood. 

Prognosis. — In  the  majority  of  instances,  this  disease  is  a  fatal  one. 
Active  treatment,  if  commenced  sufficiently  early,  may  possibly  arrest 
the  morbid  process  in  some  cases. 

Treatment. — This  will  be  discussed  under  that  of  mj^elitis. 

"non-systematic"    or    "focal   lesions"    of   THE   SPINAL   CORD.* 

By  reference  to  a  table  on  page  350,  it  will  be  seen  that  these  lesions 
differ  in  their  character  from  the  systematic  diseases  which  have  been 
described. 

The  clinical  features  which  they  present  differ  in  each  Individual  case ; 
because  they  are  modified  by  the  situation  of  the  lesion,  in  respect  to  the 
different  columns  of  the  cord  involved,  as  well  as  its  height  in  the  cord. 

The  height  of  the  lesion  is  determined  partly  by  the  region  to  which 
the  so-called  "  cincture  "  or  "  girdle  sensation  "  is  referred ;  partly  by  the 
extent  of  the  motor  paralysis  or  sensory  phenomena;  again,  by  the 
superficial  spinal  reflexes  which  are  found  to  be  unimpaired;  and,  finally, 
by  the  history  of  the  case,  when  the  scat  of  the  exciting  cause  can  be 
well  defined. 

Focal  lesions  differ  from  the  systematic  or  non-focal  lesions  in  that 
they  tend  to  spread  laterally  from  column  to  column.  They  often 
extend  to  the  gray  matter  of  the  cord,  and  sometimes  involve  the  entire 
structures  of  both  lateral  halves  of  the  organ.  At  first  such  a  lesion  may 
be  small  and  affect  only  a  limited  area ;  in  such  a  case  the  sj-mptoms  may 

*  Several  pages  which  relate  to  focal  lesions  of  the  cord  are  quoted  from  the  Author's 
work,  entitled  "  The  Applied  Anatomy  of  the  Nervous  System."  D.  Appleton  &  Co.,  N.  Y. 


"focal  lesions"  of  the  spinal  cord.  409 

be  confined  exclusively  to  cither  motor  or  sensor3'  phenomena,  depending 
upon  the  column  which  is  attiicked.  As  it  spreads  to  adjacent  cohimns, 
the  s^-mptoms  are  modified,  new  ones  being  added  which  indicate  the 
direction  Of  its  growth.  Physiological  and  anatomical  knowledge  can 
alone  aid  in  deciding  as  to  the  height  of  the  lesion  in  the  cord,  or 
the  portions  which  are  destroyed  by  it,  provided  that  the  cause  of  the 
symptoms  is  not  of  a  traumatic  character. 

Before  we  pass  to  the  consideration  of  lesions  confined  to  special 
segments  of  the  cord,  it  may  be  well  to  refer  again  to  a  few  general  state- 
ments which  have  been  made  on  page  352. 

Focal  lesions  commonly  give  rise  :  (1)  to  paresis  or  paralysis  of  the 
extremities;  (2)  to  anaesthesia  or  paraesthesiae, — such,  for  example,  as 
numbness,  formication,  etc.  ]  (3)  to  modif  cations  of  the  superficial  and 
deep  spinal  reflexes;  (4)  to  paresis  or  paralysis  of  the  bladder  and 
rectum;  and  (5)  to  a  tendency  to  bed-sores. 

The  spinal  cord  may  be  regarded  from  a  ph3'siological  stand-point 
as  composed  of  numerous  segments  whicli  are  superimposed ;  each  of 
which  is  capable  of  an  automatic  action.  In  some  of  these  are  placed 
special  centres  whicli  govern  the  action  of  the  viscera,  the  sexual  organ, 
and  the  calibre  of  blood-vessels. 

The  segments  of  the  cord  may  be  controlled,  when  necessary,  by  the 
ganglia  of  the  brain  which  are  of  a  higher  order;  but  when  this  con- 
trolling power  is  interrupted  from  any  cause,  as  in  spinal  lesions,  for 
example,  the  spinal  segments  may  still  continue  to  act  automatically. 
This  is  one  of  the  many  explanations  that  have  been  advanced  to  explain 
the  exaggeration  of  the  spinal  reflexes  (which  often  exists  when  focal 
lesions  of  the  spinal  cord  are  present),  as  well  as  the  fact  that  the  bladder, 
rectum,  sexual  apparatus,  and  the  skin  are  sometimes  affected  by  such 
lesions,  and  again  are  not. 

It  is  often  possible  and  of  great  practical  importance  to  the  diag- 
nostician to  tell  in  what  region  of  the  cord  a  lesion  is  situated,  and  to 
estimate  the  height  to  which  it  has  progressed.  Of  course,  this  is  much 
easier  in  focal  lesions  than  in  the  systematic,  because  the  different 
columns  of  the  cord  then  simultaneously  furnish  symptoms  which  can 
be  compared,  and  thus  aid  in  the  diagnosis.  In  the  table,  to  which 
I  some  time  ago  directed  attention,  j-ou  will  perceive  that  the  focal 
lesions  include  traumatisms  (of  all  forms) ;  compression  of  the  cord 
(chiefly  by  inflammatory  exudation,  bone,  and  tumors) ;  transverse 
sclerosis  of  the  cord  ;  transverse  softening  of  the  cord  ;  hemorrhage  into 
the  substance  of  the  cord;  and,  finally,  certain  tumors  which  involve  the 
cord  itself.  There  are  many  other  causes  which  might  excite  some  local 
lesion,  but  these  are  the  ones  which  will  most  frequently  come  under  the 
notice  of  the  practitioner. 


410  LECTURES   ON  NERVOUS   DISEASES. 

A  IVw  anatomical  ])oints  are  suggested  in  this  connection  as  of  value 
in  spinal  diagnosis:  (1)  the  hi/poylosHal  and  pneumogadric  ?)ert"e.s  arise 
from  the  medulla,  whieh  lies  above  the  level  of  the  axis;  (2)  the  jihrenic 
arises  on  a  level  with  the  si)ine  of  the  axis;  (3)  the  brachial  plexus  and 
the  ulnar  nerve  are  connected  with  the  cord  in  the  region  of  the  neck 
(third  and  sixth  cervical  spines)  ;  (4)  the  cilio-spinal  centre  is  situated 
between  the  fifth  cervical  and  the  second  dorsal  vertebrae;  (5)  the  lumbar 
enlargement  of  the  cord  gives  otf  the  crural  and  sciatic  nerves  at  diti'erent 
points,  and  the  space  between  the  eleventh  dorsal  and  the  second  lumbar 
spines  includes  the  point  of  origin  of  both;  (6)  the  spinal  cord  ends  at 
the  second  lumbar  s/J^?^e,  although  the  nerves  continue  to  escape  from  the 
spinal  canal  much  below  that  point. 

Before  we  discuss  the  various  conditions  enumerated  in  a  previous 
table  as  "  focal  lesions  "  of  the  cord  (page  350)  as  separate  diseases,  it 
maj'  be  advisable  to  consider  in  a  general  way  the  effects  of  focal  lesions 
of  tlie  cord  at  dift'erent  levels.     These  may  be  made  use  of  in  diagnosis. 

We  have  already  studied  the  effects  of  systematic  lesions,  both  of 
the  kinesodic  and  aisthesodic  systems,  and  liuve  noticed  how  perfectl}' 
the  physiology  of  the  spinal  cord  is  confirmed  by  lesions  affecting 
the  anterior  or  posterior  portions  of  the  cord  separately.  We  are  now 
called  upon  to  investigate  those  lesions  which,  by  extending  in  a  trans- 
verse direction,  are  liable  to  be  accompanied  by  symptoms  referable  to 
both  the  sensory  and  motor  portions  of  the  cord. 

Of  course,  the  symptoms  will  be  modified  b}'  the  extent  of  the  lesion 
in  a  transverse  direction,  so  that  they  may  be  mostly  sensory  or  motor; 
but  the  presence  of  both  sensory  and  motor  svmptoms  is  stronghj 
diagnostic  of  focal  lesions,  irrespective  of  a  predominance  of  either, 
and  is  never  produced  by  any  systematic  lesion  of  the  cord,  with  the  one 
exception  of  central  myelitis. 

We  may  start  with  a  general  statement  in  our  study  of  focal  lesions, 
as  follows  :  Focal  lesions  usually  give  rise  to  paralysis  of  motion  ;  to  an 
alteration  in  the  reflex  excitabiliti/  of  the  cord  (usually  an  increase) ;  and 
to  more  or  less  ansesthesia,  numbness,  and  pa???.  The  bladder  and  rectum 
are  often  paralyzed,  and  a  tendency  to  bed-sores  is  frequently  i)roduced. 
Tlie  first  two  of  these  effects,  and  also  the  last,  are  due  to  alteration 
in  the  kinesodic  system ;  the  remaining  ones  are  the  result  of  some 
disturbance  to  the  sesthesodic  system. 

In  studying  focal  lesions  situated  in  different  regions  of  the  spinal 
cord,  we  must  adopt  some  sj'stem  if  we  expect  to  grasp  the  fine  distinc- 
tions which  can  be  drawn  between  the  results  of  lesions  of  the  upper 
cervical  region,  the  cervical  enlargement,  the  mid-dorsal  region,  the 
region  just  above  the  lumbar  enlargement,  and,  finally,  the  lumbar 
enlargement  itself. 


"focal  lesions"  of  the  spinal  coed.  411 


FOCAL    LESION    IN    THE,  UPPER    CERVICAL    REGION. 

Hemiplegia  will  be  produced  if  one  lateral  half  of  the  cord  be  alone  afiected ; 
while  paraplegia  will  be  present  if  the  lesion  extends  transversely  to  both  lateral  halves 
of  the  cord.  The  hemiplegia  or  paraplegia  will  be  complete  below  the  head,  and  the 
entire  body  may  be  rendered  anajsthetic.  Since  the  phrenic  nerve  arises  at  this  point, 
the  act  of  respiration  will  be  interfered  with,  creating  dyspnoja  and  hiccough ;  but 
respiration  will  not  be  arrested,  since  the  pneumogastric  nerves  continue  to  excite  it,  and 
the  auxiliary  muscles  of  respiration  can  expand  the  chest  without  the  action  of  the 
diaphragm.  Should  the  lesion  be  a  surgical  one  (as  it  usually  is),  the  respiratory  centre 
of  the  medulla  may  be  affected,  and  death  take  place  from  asphyxia;  but  I  do  not  think 
such  a  result  can  be  explained  as  a  simple  effect  of  paralysis  of  the  j)hrenic  nerves  alone. 
The  involvement  of  the  cilio-spvnal  centre  in  the  lower  cervical  region  may  cause  the 
pupils  to  show  an  irregularity,  and  the  face  and  neck  may  manifest  a  marked  increase  of 
temperature.  The  pulse  may  be  rendered  variable,  from  irritation  of  or  yiressure  upon 
the  acceleratory  centre  of  the  heart. 

Now,  as  I  have  before  said,  this  type  of  lesion  is  almost  always  a  surgical  one,  com- 
prising pressure  from  fracture,  dislocation,  caries,  tumors  of  the  vertebrae,  etc.  These 
cases  seldom  live  long  enough  for  us  to  study  the  effects  of  such  a  lesion  with  much  detail. 
In  those  rare  instances  where  the  lesion  is  non-traumatic  and  slowly  developed,  the 
effects  of  irritation  have  been  shown  in  a  hiccough  (probably  due  to  irritation  of  the 
]ihrenic  nerve),  acceleration  of  the  pulse  (from  irritation  of  the  acceleratory  centre  of 
the  heart),  and  dyspnoea  (from  some  interference  with  the  phrenic  nerve  or  the  nucleus 
of  the  pneumogastric  nerve  in  the  medulla) ;  while  the  paralysis  has  first  appeared  as  a 
paretic  condition  of  the  arms,  then  of  the  chest,  and,  finally,  of  the  lower  limbs. 

FOCAL   LESIONS   OF    THE   CERVICAL   ENLARGEMENT. 

This  type  of  lesion  differs  in  its  effects  if  developed  suddenly  or  gradually,  and  also 
when  situated  in  the  upper  or  the  lower  part  of  the  enlargement.  If  the  lesion  be  so 
situated  as  to  create  only  irritation  of  the  cilio-spinal  centre,  or  the  acceleratory  centre  for 
the  heart  (both  of  which  are  in  that  vicinity),  the  effects  will  differ  from  those  due  to 
actual  pressure  upon  or  destruction  of  those  centres.  In  the  first  instance,  the  pupils  will 
usually  be  dilated  and  the  face  pale,  while  the  heart  will  be  accelerated ;  in  the  latter,  the 
]nipils  will  generally  be  contracted,  the  face  and  neck  flushed,  and  the  pulse  retarded. 
The  effects  will  also  differ  if  the  lesion  affects  both  lateral  halves  of  the  cord  or  only  one. 

Wherever  the  lesion  be  situated  within  the  cervical  enlargement,  the  arms  and  legs 
will  gradually  become  paralyzed ;  the  arms  and  hands  usually  becoming  first  numb  and 
paretic,  and  the  lower  limbs  exhibiting,  for  some  time,  only  a  sense  of  weakness  and 
evidences  of  an  increased  reflex  excitability.  A  sense  of  constriction  around  the  chest 
(the  so-called  "cincture  feeling")  is  generally  present,  the  seat  of  which  varies  with  that 
of  the  exciting  lesion. 

When  the  lesion  is  situated  at  the  upper  part  of  the  enlargement,  the  motor  and 
sensory  symptoms  will  be  manifested  in  the  lower  extremities,  the  trunk,  and  in  nearly  all 
the  regions  of  the  upper  extremities.  The  constricting  band  around  the  thorax  is 
referred  to  the  level  of  the  clavicles,  and  dyspncea  is  often  excessive. 

The  brachial  plexus  is  associated  with  the  upper  part  of  the  cervical  enlargement, 
and  the  ulnar  nerve  with  the  lower  part ;  hence,  the  paralysis  of  the  arms  in  this  case 
would  naturally  be  manifested  in  almost  all  of  the  regions  of  the  upper  extremity,  and 
also  in  those  parts  supplied  by  the  brachial  plexus  above  the  clavicle. 


412  LECTURES   ON  NERVOUS  DISEASES. 

If  the  lesion  be  situated  in  the  lower  part  of  the  cervical  enlargement,  the  symptoms 
exhibited  will  include  a  loss  of  faradaic  reaction  of  those  muscles  which  are  suiiplied  by 
the  ulnar  nerve  (rather  than  those  of  the  arm  and  the  extensors  of  the  forearm),  and 
atrophy  of  these  muscles  will  often  be  developed,  chiefly  in  the  flexors  of  the  wrist  and 
the  small  muscles  of  the  hand.  The  sense  of  constriction  (cincture  feeling)  experienced 
in  most  spinal  lesions  of  a  local  character  will  exist,  but  it  will  be  referred  to  the  upper 
part  of  the  chest.  A  paralytic  condition  of  the  muscles  of  the  trunk  (the  intercostals, 
triangularis  sterni,  and  the  accessory  muscles  of  respiration),  as  well  as  of  the  abdominal 
muscles,  will  be  detected  in  severe  cases,  rendering  both  inspiration  and  expiration 
embarrassed,  and  thus  adding  to  the  danger  to  life.  The  lower  limbs  may  exhibit  evi- 
dences of  numbness,  anaesthesia,  paresis,  or  comjilete  paralysis,  depending  upon  the  extent 
of  the  lesion  and  the  destruction  done  to  the  tissues  of  the  cord.  A  condition  of  paralysis 
may  also  exist  in  the  upper  extremity. 

In  surgical  injuries  to  the  upper  portion  of  the  cord,  a  peculiarity  is  often  noticed  in 
the  temperature  of  the  body,  which  is  sometimes  greatly  elevated.  This  clinical  feature 
may  be  associated  with  a  marked  retardation  of  the  action  of  the  heart  (apparently 
confirming  the  situation  of  an  acceleratory  centre  for  that  organ  in  the  spinal  cord). 

FOCAL   LESIONS   OF    THE    MID-DORSAL   REGION    OF    THE   SPINAL   CORD. 

In  the  early  stages  of  these  conditions  the  lower  limbs  become  paretic,  and  a 
condition  of  increased  reflex  excitability  is  manifested  by  a  rigidity  and  stifi"nes3  of  the 
impaired  muscles  whenever  the  patient  attempts  to  stand  or  walk.  As  the  disease 
progresses,  the  muscles  become  paralyzed  and  contractured*  (probably  on  account  of 
changes  of  a  secondary  character  in  the  lateral  columns  of  the  cord).  In  some  cases  the 
reflex  movements  assume  the  type  of  spasms,  so  as  to  exhibit  both  tonic  and  clonic  con- 
tractions. It  was  this  symptom  which  suggested  to  Brown-Sequard  the  name  of  "  spinal 
epilepsy,"  since  it  occurs  when  the  patient  is  exposed  to  the  slightest  peripheral  irritation, 
and  often  when  in  the  recumbent  posture. -f-  The  sense  of  constriction  around  the  body  is 
referred  to  the  region  of  the  navel,  or  that  of  the  lower  ribs,  or  possibly  as  high  as  the 
axilla,  since  it  may  be  taken  as  a  relative  guide  to  the  highest  limit  of  the  lesion.  A 
peculiarity  exists  in  this  condition  as  regards  the  bladder  and  the  rectum;  although  they 
may  be  paralyzed,  they  are  often  enabled  by  the  aid  of  reflex  action  to  expel  their 
contents,  thus  apparently  having  regained  their  function.  In  the  early  stages  the  urine 
and  feeces  may  be  too  hastily  expelled  for  the  comfort  of  the  patient,  often  compelling  the 
performance  of  either  act  before  a  proper  place  can  be  reached;  but,  in  the  advanced 
stages  the  urine  is  retained  to  such  an  extent  as  to  cause  an  "overflow,"  which  is  oft«n 
mistaken  for  an  actual  incontinence,  since  a  constant  dribbling  is  present.  This  symptom 
is  always  an  indication  for  the  regular  use  of  a  catheter.  The  sexual  function  seems  to  be 
often  unimpaired,  as  coition  is  frequently  possible.  It  is  seldom  that  the  paralyzed 
muscles  exhibit  a  tendency  to  atrophy,  and  the  electrical  reaction  of  the  affected  parts  is 
either  normal  or  exaggerated.  The  chief  seat  of  weakness  is  usually  first  detected  in  the 
feet ;  subsequently  the  paralysis  gradually  involves  the  entire  lower  limbs. 

FOCAL   LESIONS   ABOVE    THE   LUMBAR   ENLARGEMENT    OF    THE    SPINAL   CORD. 

In  this  sit^uation,  a  focal  lesion  of  the  cord  produces  about  the  same  sensory  and 
motor  symptoms  as  those  described  in  connection  with  a  lesion  of  the  mid-dorsal  region, 

*  A  term  used  in  contradistinction  to  the  word  "  contracted,"  to  designate  a  permanent 
shortening  rather  than  a  temporary  response  to  a  motor  impulse. 

t  The  presence  of  urine  in  the  bladder  or  of  faeces  in  the  rectum  may  often  crepte 
these  spasms. 


"focal  lesions"  of  the  spinal  cord.  413 

with  the  exception  that  the  reflex  spasms,  present  in  the  paralyzed  muscles,  are  jierhaps 
somewhat  less  violent  than  when  the  lesion  is  higher  up  the  cord.  These  tonic  and  clonic 
spasms  are,  however,  suiiiciently  well  marked  to  constitute  a  prominent  symptom,*  and 
they  indicate  an  increased  reflex  excitability  of  the  gray  matter  of  the  cord  below  the  seat 
of  the  lesion.  An  ingenious  explanation  of  this  increased  reflex  has  been  advanced  by 
Professor  Seguin,  of  this  city,  which  seems  to  merit  respectful  consideration.  I  quote 
from  a  paper  of  his  upon  affections  of  tlie  spinal  cord,  as  follows : — 

"  The  classic  theory  of  the  physiology  of  contracture  in  hemiplegia  is  that  it  is  due  to 
the  secondary  degeneration;  i.e.,  actively  caused  by  the  lesion  of  the  postero-lateral 
column.  Seven  years  ago  (see  Archives  of  Scientific  and  Practical  Medicine,  vol.  i, 
p.  106,  1873,)  I  rejected  this  hypothesis,  and  suggested  a  different  one,  which  I  have  since 
elaborated  and  taught  in  my  clinical  lectures.  This  hypothesis,  which  I  intend  shortly  to 
publish  in  detail,  is  briefly  that  the  spasm  is  due,  not  to  direct  irritation  from  the 
sclerosed  (?)  tissue  in  the  postero-lateral  column,  but  to  the  cutting  off  of  the  cerebral 
influence  by  the  primary  lesion,  and  the  consequent  preponderance  of  the  proper  or 
automatic  spinal  action — an  action  which  is  mainly  reflex.  This  theory  explains  the 
phenomena  observed  in  cases  of  primary  spinal  diseases  with  descending  degeneration, 
and  can  be  reconciled  with  results  of  experiments  on  animals  (increased  reflex  power  of 
spinal  cord  after  a  section  high  up,  Brown-Sequard;  inhibitory  power  of  the  encephalon 
on  the  spinal  cord,  Setchenow)." 

The  urinary  and  rectal  organs  are  affected  in  about  the  same  way  as  in  lesions  of  the 
dorsal  region.  Coition  is  often  possible,  and  erections  are  normally  frequent.  The  rectum 
is  paralyzed,  as  a  rule,  and  constipation  is  usually  present  on  that  account.  Micturition 
becomes  slow  and  interrupted,  as  the  bladder  grows  paretic,  and  retention  and  overflow  are 
produced  later  on  in  the  disease. 

The  paralysis  of  the  extremities  is  first  noticed  in  the  feet,  which  have  long  before 
exhibited  a  sense  of  weakness  and  easy  fatigue.  Numbness  and  anaesthesia  usually 
accompany  the  motor  paralysis,  and  extend  as  high  as  the  groin  or  the  waist.  The  sense 
of  a  constricting  band  around  the  body  is  present  here,  as  in  lesion  of  other  localities,  and 
is  referred  to  the  waist,  below  the  level  of  the  umbilicus,  or  at  the  level  of  the  hips. 

FOCAL   LESIONS   OF    THE   LUMBAR   ENLARGEMENT. 

The  lower  portion  of  the  lumbar  enlargement  gives  origin  to  the  sciatic  nerve;  hence, 
it  is  reasonable  to  expect  that  a  lesion  situated  in  the  lower  part  of  this  enlargement 
would  be  manifested  by  symptoms  of  an  incomplete  paraplegia,  in  which  the  muscles 
supplied  by  the  sciatic  nerves  would  be  the  most  affected.  Now,  this  fact  seems  to  be 
confirmed  by  clinical  experience,  since  the  feet,  legs,  posterior  aspect  of  the  thighs,  and  the 
region  of  the  nates  are  chiefly  paralyzed  when  the  lesion  is  so  situated.  The  bladder  is 
unaffected,  but  the  sphincter  ani  muscle  is  often  rendered  paretic,  or  it  may  be  entirely 
paralyzed.  The  portions  of  the  limbs  which  are  to  become  the  seat  of  paralysis  usually 
exhibit  a  sense  of  numbness  before  the  effects  of  the  lesion  are  fully  developed,  and,  in  case 
the  posterior  columns  of  the  cord  be  involved,  complete  ansesthesia  may  also  exist  in  the 
parts  supplied  with  motor  power  by  the  sciatic  nerve.  The  condition  of  the  paralyzed 
muscles,  as  to  their  electrical  reactions,  and  the  presence  or  absence  of  the  evidences  of 
increased  reflex  excitability  will  depend  greatly  upon  how  much  damage  has  been  done 
to  the  gray  matter  of  the  lumbar  enlargement.  If  the  gray  matter  be  so  destroyed  as  to 
impair  its  function,  the  reflex  movements  will  be  absent;  and,  if  the  trophic  function  of 
the  cord  be  affected  by  changes  in  the  ganglion  cells  of  the  gray  matter,  the  paralyzed 

*  These  reflex  spasms  have  been  called  by  Brown-S^quard  "  spinal  epilepsy." 


414  LECTUEES   ON   NERVOUS   DISEASES. 

muscles  will  undergo  atroph_y.     The  sense  of  constriction,  or  "band  feeling,"  will  usually 
be  referred,  in  this  lesion,  either  to  the  ankle,  leg,  or  thigh. 

FOCAL   LESIONS   CONFINED   TO   THE    LATERAL    HALF   OF   THE    SPINAL  CORD. 

In  discussing  the  focal  lesions  of  the  cord,  we  have  described  the  clinical  points  which 
are  afforded  by  destruction,  to  a  greater  or  less  extent,  of  the  substance  of  the  cord  in  both 
of  its  lateral  halves ;  hence  the  motor  and  sensory  symptoms  have  been  usually  referred 
to  both  sides  of  the  body.  It  was  necessary  to  thus  describe  them,  since  focal  lesions, 
unless  traumatic,  are  seldom  confined  to  one  lateral  half  of  the  cord ;  but,  in  some  cases 
which  may  be  presented  to  your  notice,  where  a  tumor,  a  fractured  vertebra,  a  hemorrhage, 
a  severe  contusion,  or  some  other  localized  lesion  exists,  the  injury  done  to  the  spinal  cord 
may  be  confined  exclusively  to  one  lateral  half,  resulting  in  one  of  two  named  conditions, 
viz.,  "spinal  hemiplegia"  and  " hemi-paraplegia." 

Any  lesion  of  a  lateral  half  of  the  spinal  cord  must  produce  anassthesia  on  the 
opposite  side  of  the  body,  since  all  the  sensory  nerves  decussate  and  enter  the  gray  matter 
of  the  cord,  which  serves  as  a  conducting  medium  for  sensory  impressions,  while  the  motor 
symptoms  produced  by  the  same  lesion  must  be  confined  to  the  same  side  of  the  body  as  the 
lesion,  since  no  decussation  probably  occurs  in  the  spinal  cord  (these  fibres  decussating 
only  in  the  medulla  oblongata). 

Lateral  lesions,  as  well  as  those  which  affect  the  entire  cord,  are  modified,  as  regards 
their  symptomatology,  by  the  height  of  the  lesion  in  the  cord;  since  the  motor  nerves,  and 
the  special  centres  which  are  situated  in  the  cord  itself,  will  only  be  affected  when  they  lie 
below  the  seat  of  the  lesion,  or  are  directly  involved  in  the  destructive  process. 

When  the  focal  lesion  is  placed  high  up  in  the  substance  of  the  spinal  cord,  the  motor 
paralysis  affects  one  side  only  of  the  body  (provided  the  lesion  is  confined  to  a  lateral 
half),  and  the  term  "spinal  hemiplegia"  is  applied  to  this  form  of  paralj'sis  in  contra- 
distinction to  a  hemiplegia  of  cerebral  origin.  If  the  spinal  lesion  be  situated  in  the 
dorsal  region  and  be  confined  to  the  lateral  half  of  the  cord,  a  motor  paralysis  of  ojie 
half  of  the  same  side  of  the  body  below  the  seat  of  the  lesion  is  developed, — a  condition  to 
which  the  term  "hemi-paraplegia"  is  commonly  applied.  In  closing  the  clinical  aspects 
of  lesions  of  the  spinal  cord,  it  will  be  necessary,  therefore,  for  us  to  consider  the  essential 
features  of  these  two  remaining  conditions. 

SPINAL   HEMIPLEGIA. 

In  order  to  produce  a  typical  case  of  this  condition,  it  is  necessars'-  to  have  a  lateral 
focal  lesion  of  the  cord  in  its  uppermost  part  (in  or  above  the  cervical  enlargement  of  the 
cord).  If  we  suppose,  then,  that  such  a  lesion  be  present,  let  us  see  what  we  might 
reasonably  expect,  on  purely  physiological  grounds,  would  be  the  result.  We  can  then 
examine  the  clinical  records  of  such  cases,  and  either  confirm  our  deductions  or  gain  some 
additional  information.  Such  a  lesion  would,  in  the  first  place,  shut  off  all  motor  impulses 
sent  out  from  the  brain  to  parts  below  the  lesion,  on  the  same  side  as  the  lesion,  since  the 
decussation  of  the  motor  fibres  has  alread}^  taken  place  in  the  medulla;  hence,  motor 
paralysis  should,  theoretically,  occur  in  the  arm  and  leg  of  the  side  of  the  body  corre- 
sponding to  the  seat  of  the  exciting  lesion,  and  the  trunk  should  also  be  paralyzed  upon 
that  side.  This  we  find  clinically  to  be  true,*  with  the  exception  that  the  intercostal 
nerves  often  retain  their  motor  power  when  the  nerves  of  the  arm  and  leg  are  no  longer 

*The  researches  of  Bro\vn-S^quard,as  early  as  1840,  and  his  published  memoirs  (18(53- 
6.5,  and  18H8,  18(>0)  have  probably  done  more  to  clear  up  this  field  and  to  place  it  upon  a 
positive  foundation  than  those  of  any  other  observer. 


SPINAL   MENINGITIS.  415 

capable  of  carrj'ing  motor  impulses.  In  the  second  place,  we  should  expect  to  find  that 
the  sensation  of  the  side  of  the  body  opposite  to  the  seat  of  the  lesion  would  be  destroyed 
or  greatly  impaired,  since  the  sensory  nerves  decussate  throughout  the  entire  length  of  the 
cord.  This  we  also  find  confirmed  by  clinical  facts;  and  so  perfect  is  this  anaesthesia  that 
the  line  can  often  be  traced  to  the  mesial  line  of  the  body  exactly,  and  upward  to  the  limit 
of  the  exciting  lesion.  In  the  third  place,  the  situation  of  the  cilio-spinal  centre  in  the 
cervical  region  of  the  cord  would  naturally  suggest  some  efi'ects  upon  the  pupil,  and  the 
circulation  and  temperature  of  the  face,  neck,  and  ear  of  the  same  side.  This  is  also 
confirmed,  as  the  pupil  does  not  respond  to  light,  but  it  still  acts  in  the  accommodation 
of  vision  for  near  objects,  and  the  skin  of  the  regions  named  becomes  red  and  raised  in 
temperature.  Finally,  the  presence  of  vaso-motor  centres  in  the  cord  might  occasion  a 
rise  in  temperature  in  the  paralyzed  muscles ;  and,  strangely  confirmator}'  of  this  fact,  we 
often  find  the  temperature  of  the  paralyzed  side  of  the  body  hotter  than  fhat  of  the 
anaesthetic  side. 

In  some  exceptional  cases,  the  face,  arm,  and  trunk  are  alone  paralyzed,  the  legs  seem- 
ing to  escape,  and  often  giving  evidence  of  reflex  spasm  (perhaps  most  commonly  on  the 
anoBsthetic  side).  This  must  be  explained  as  the  result  of  incomplete  destruction  of  the 
lateral  half  of  the  cord. 

HEMI-PARAPLEGIA. 

This  condition  is  the  result  of  some  focal  lesion  of  the  spinal  cord  in  the  dorsal  region, 
which  involves  only  its  lateral  half.  The  results  of  such  a  lesion  differ  but  little  from  those 
of  one  causing  spinal  hemiplegia,  as  regards  the  motor  and  sensory  symptoms,  excepting 
that  the  situation  of  the  exciting  cause  is  below  the  cervical  enlargement,  where  the  nerves 
to  the  upper  extremity  are  given  off,  and  where  the  cilio-spinal  centre  is  situated.  For 
that  reason  the  muscles  of  the  upper  extremity  are  not  paralyzed,  nor  are  the  effects  upon 
the  pupil  and  the  skin  of  the  face,  ear,  and  neck  (mentioned  as  present  in  spinal  hemiplegia) 
produced.  The  muscles  below  the  seat  of  the  lesion  are  paralyzed  on  the  side  of  the  body 
corresponding  to  the  exciting  cause,  and  the  skin  is  sometimes  rendered  hyperaesthesic  upon 
that  side  ;*  while  the  integument  of  the  side  opposite  to  the  lesion  is  deprived  of  sensibility. 
The  bladder  and  rectum  may  be  paralyzed  in  some  instances.  The  sense  of  constriction, 
or  "band  feeling,"  will  vary  with  the  seat  of  disease  in  the  spinal  cord.  The  amount  of 
reflex  irritability  and  the  presence  or  absence  of  muscular  atrophy  in  the  parts  paralyzed 
will  depend  upon  the  depth  of  the  lesion  in  the  spinal  cord  and  the  changes  which  have 
been  produced  in  the  gray  matter.  The  same  increase  of  temperature  in  the  paralj-zed 
limb,  which  was  mentioned  as  occurring  in  spinal  hemiplegia,  may  also  be  present  in  this 
variety  of  paralysis. 

Should  the  side  affected  with  anaesthesia  give  any  evidence  of  motor  paralysis  or 
muscular  weakness,  or  symptoms  of  anfesthesia  appear  upon  the  side  where  the  motor 
paralysis  is  present,  you  may  regard  either  one  as  conclusive  evidence  that  the  exciting 
lesion  is  progressing,  and  that  the  opposite  lateral  half  of  the  cord  is  being  involved  to  a 
greater  or  less  extent. 

SPINAL   MENINGITIS. 

{Pachymeningitis  Spinalis — Lejyfomeningitis  Sjnnalis.) 

The  membranes  of  the  spinal  cord  may  become  inflamed  inde- 
pendently of,  or  in  conjnnction  with,  similar  changes  in  the  cerebral 
envelopes.     I  shall  discuss  the  former  variety  here. 

*  This  is  probably  due  to  some  irritation  of  the  gray  matter  of  the  cord. 


416  LECTURES   ON  NERVOUS   DISEASES. 

Spinal  meningitis  may  be  of  two  forms :  (1)  pachymeningitis 
(internal  and  external  varieties),  and  (2)  leptomeninyitis  (acute  and 
chronic  varieties).  I  have  chosen  to  include  both  of  these  conditions 
among  the  focal  lesions  of  the  cord,  because  their  effects  upon  the 
functions  of  that  organ  are  due  chiefly  to  pressure.  The  pressure  so 
produced  is  liable  to  spread  in  a  lateral  direction  from  column  to  column 
of  the  cord. 

Although  the  acute  variety  of  leptomeningitis  (inflammation  of  the 
pia  and  arachnoid)  is  generally  diffused  over  a  much  larger  area  than 
the  chronic,  the  distinction  drawn  on  a  previous  page  between  systematic 
and  focal  lesions  of  the  cord  (see  table  on  p.  350)  clearly  justifies  the 
classification  adopted. 

When  the  symptomatology  of  this  disease  is  reached,  man}^  of  the 
hints  given  in  connection  with  the  diagnosis  of  focal  lesions  (p.  411  to 
415)  will  prove  of  great  assistance  to  the  reader. 

Morbid  Anatomy. — In  the  acute  variety  of  leptomeningitis,  the  mem- 
branes (chiefly  the  pia)  are  rendered  thicker  than  normal,  more  or  less 
opaque  and  (Edematous,  sometimes  ecchj'motic,  and  often  adherent  to 
each  other.  The  meshes  of  the  i)ia  are  filled  with  a  turbid  exudation, 
which  may  be  tinged  with  blood.  It  is  sometimes  clear,  but  generallj' 
more  or  less  filled  with  flocculi  of  lymph.  The  consistency  of  this 
exudation  varies.  It  ma^^  be  fluid,  or  of  the  density  of  jellj'.  It  is 
usually  most  abundant  at  the  posterior  part  of  the  cord  and  around  the 
posterior  nerve-roots ;  but  it  may  envelop  the  entire  circumference  of 
the  cord. 

In  the  arachnoid,  hard  cartilaginous  plates  are  occasionally  detected. 
Tlie  size  of  the  plates  may  reach  a  quarter  of  an  inch  in  diameter,  but 
they  are  usually  much  smaller. 

The  dura  may  become  involved  in  conjunction  with  the  arachnoid 
and  pia;  or  it  may  be  separately  affected,  as  is  also  the  case  with  the 
dura  lining  the  cavity  of  the  cranium.  We  may  thus  have  an  internal 
and  external  variety  of  spinal  pachymeningitis,  as  well  as  leptomeningitis 
(inflammation  of  the  pia). 

The  external  form  of  spinal  pachymeningitis  is  primarily  an 
affection  of  the  dura.  The  other  membranes  may,  however,  occasionally 
become  involved  by  an  extension  of  the  inflammatory  process.  Its  most 
common  seat  is  in  the  cervical  region,  and  it  seldom  extends  bej'ond  the 
limits  of  two  vertebrae.  Several  such  foci  of  inflammation  may  coexist. 
The  membranes  become  hypertrophied  and  encroach  upon  the  spinal 
canal.  This  may  result  in  a  compression  of  the  spinal  cord.  Myelitis 
may  be  thus  induced.  Again,  the  roots  Of  the  spinal  nerves  may  be 
compressed  by  the  changes  in  the  membranes  through  which  they  pass, 
thus  causing  disturbances  of  sensibility  and  motility. 


SPINAL   MENINGITIS.  417 

The  external  variety  of  pachj-meniiigitis  spinalis  is  confined  to  the 
loose  connective  tissue  between  the  dura  and  tlie  vertebral  canal.  This 
is  more  abundant  in  the  posterior  part  of  the  spinal  canal  than  elsewhere  ; 
a  fact  which  helps  to  explain  the  circumscribed  character  of  its  morbid 
changes,  as  well  as  the  tendency  of  these  changes  to  become  most 
marked  posteriorly. 

Swelling  and  redness  are  generally  to  be  detected  at  the  seat  of  the 
extra-dural  cellulitis.  Abscesses  may  develop  in  exceptional  instances. 
In  other  cases  the  dura  is  simplj-  thickened  and  adherent ;  or  dry,  cheesy 
masses  of  considerable  size  nia}^  be  detected. 

The  pains,  which  are  a  prominent  symptom  of  the  first  stage  of  this 
affection,  are  probably  due  to  a  slight  compression  of  the  posterior  nerve- 
roots.  Rigidity  of  muscles  may  also  occur  from  a  similar  condition  of 
the  anterior  nerve-roots.  Later  on,  the  compression  of  the  cord  may 
induce  paralysis,  contracture,  and  atrophy  of  muscles  (chiefly  those 
supplied  by  the  median  and  ulnar  nerves),  anaesthesia  of  limited  areas 
of  the  body,  and  possibly  sj^mptoms  of  incoordination  of  movement. 
We  owe  most  of  our  knowledge  of  this  aflfection  to  the  publications  of 
Charcot. 

The  internal  form  of  spinal  jMchymeninciitis  (the  hemorrhagic 
variety)  was  first  fully  described  by  Meyer,  although  it  was  partially 
recognized  by  Albers.  A  laminated  sac  enclosing  a  hemorrhagic  con- 
dition of  the  spinal  membranes  exists  in  this  disease,  which  is  identical 
witli  that  described  in  connection  with  the  dura  of  the  cranium.  It 
seems  to  occur  in  connection  with  alcoholism,  some  cases  of  insanity, 
general  paralysis,  caries  of  the  bones,  and  syphilis. 

This  form  of  spinal  pachymeningitis  usually  runs  a  chronic  course. 
It  is  not  always  of  the  hemorrhagic  variety.  The  dura  presents  in  rare 
cases  upon  its  inner  surface  a  series  of  concentric  lamellae  of  a  fibrous 
character,  while  the  arachnoid  and  pia  have  become  simdarly  afl'ected, 
constituting  the  so-called  "  hyperti'ophic  internal  spinal  jyachi/meyiingitis.''^ 

In  this  disease,  the  spinal  cord  is  constricted  by  a  ring  of  fibrous 
tissue  (with  numerous  interstitial  spaces)  whose  concentric  lamellae  may 
exceed  one-twentieth  of  an  inch  in  thickness.  This  ring  is  generally 
situated  in  the  lower  half  of  the  cervical  enlargement  of  the  cord.  It 
tends  to  compress  the  spinal  nerve-roots,  and  later  the  substance  of  the 
cord  itself.  When  the  latter  occurs  the  spinal  gray  matter  is  apt  to 
suflTer.  Frequently  newly-formed  canals  are  detected  near  to  the  gray 
commissure,  which  are  lined  with  a  membrane  and  contain  fluid. 

When  spinal  meningitis  is  developed  in  connection  with  syphilis, 
the  lesion  is  usually  of  the  type  of  gummata,  and  is  more  or  less  circuni- 
scribed.  The  antero-lateral  portions  of  the  cord  are  more  often  involved 
than  the  posterior;   hence,  we  are  more  apt  to  encounter  disorders  of 


418  LECTURES   ON   NEllVOUS   DISEASES. 

motility  than  of  sensation  or  coordination.  When  these  gnmmata  are 
not  multiple,  the^^  are  commonly  found  in  the  region  of  the  lower  dorsal 
and  upper  lumbar  segments  of  the  cord.  If  multiple,  they  may  occa- 
sionally be  detected  higher  up. 

In  the  chronic  variety  of  spinal  leptomeningitis,  the  membranes 
are  excessively  thickened  and  i)uckered.  The  adhesions  are  also 
abundant  and  very  firm.  Finally,  the  opacity  of  the  membranes  is 
greater  than  in  the  acute  form.  In  some  cases  pigmentation  exists. 
Calcareous  plates  within  the  membranes  are  not  uncommon.  The 
amount  of  fluid  wuthin  the  subarachnoidean  space  is  increased,  and  may 
contain  flocculi  of  lymph,  with  pus,  or  blood.  The  cord  is  generally 
angemic  and  frequently  sclerosed.  The  nerve-roots  are  usually  more  or 
less  degenerated  and  atrophied. 

Etiology. — Among  the  predisposing  causes,  bad  hygienic  surround- 
ings, an  excessive  use  of  alcohol  and  tobacco,  indulgence  in  narcotics, 
exposure  to  cold  or  dampness,  rheumatism,  venereal  excesses,  scrofula, 
wasting  diseases,  tuberculosis,  and  general  debility  may  be  mentioned  as 
prominent. 

The  exciting  causes  comprise  injuries  to  the  spine  of  all  kinds, 
operations  for  spina  bifida,  syphilis,  alcoholismus,  some  of  the  diseases 
of  the  cord,  tumors  of  the  cord  or  its  meninges,  caries  of  the  vertebra?, 
tetanus,  hydrophobia,  cancer,  spinal  concussion,  infectious  febrile 
diseases,  and  rheumatism. 

External  pachymeningitis  is  almost  always  a  secondary  disease. 
Amono-  the  primary  conditions  which  may  induce  it  by  extension 
through  the  intervertebral  foramina,  may  be  mentioned  caries  of  the 
vertebrae,  suppurations  in  the  neck  or  pharynx,  tuberculosis,  pleurisy, 
empyema,  peritonitis,  pelvic  suppuration,  syphilitic  ulceration,  etc. 

Youth  and  early  adult  life  are  more  prone  to  this  disease  than  old 
SLse.  It  is  most  frequent  in  males.  The  acute  form  is  liable  to  be 
followed  by  the  chronic.  Spinal  pachymeningitis  is  a  very  common 
complication  of  Pott's  disease. 

Leptomeningitis  is  most  frequently  met  with  during  the  winter 
months.  Sun-stroke  is  said  by  some  authors  to  induce  it,  but  I  think 
such  instances  must  be  very  rare.  The  chronic  variety  generally  coexists 
with  locomotor  ataxia,  multiple  spinal  sclerosis,  myelitis,  and  other 
organic  spinal  diseases. 

Symptoms. — The  most  important  and  marked  symptom  of  the  onset 
of  leptomeningitis  is^wm.  This  may  be  localized  in  the  back,  or  it  may 
shoot  into  those  pai'ts  which  are  associated  with  the  segments  of  the  cord 
nearest  to  the  seat  of  inflammation.  The  pain  is  generally  constant, 
but  it  may  often  be  intensified  by  movements  of  the  spine,  pressure 
over  the  spinous  processes,  or  the  application  of  an  electric  current  to 


SPINAL   MENINGITIS.  419 

the  spine.  Like  some  other  S3']ni)toms  "uhich  occur  early,  it  maj^  be 
regarded  as  a  clinical  evidence  of  irritation  of  the  posterior  nerve-roots. 

A  chill  or  severe  rigor  may  usher  in  this  disease  in  some  cases.  It 
is  often  followed  by  nausea,  vomiting,  a  moderate  rise  in  temperature,  and 
a  sense  of  weakness.  The  pulse  is  seldom  greatly  accelerated  :  it  may 
even  be  below  the  normal  standard. 

Soon  a  rigidity  of  the  muscles  of  the  spine  appears.  Opisthotonos 
is  developed  in  some  cases,  especially  when  the  cervical  region  is  in- 
volved. The  patient  generally  maintains  a  fixed  position,  since  move- 
ment intensifies  the  pain. 

Convulsive  txoitchimjs  of  the  muscles  may  be  developed.  They  are 
exceedingly  painful. 

The  spinal  reflexes  will  be  found,  as  a  rule,  to  be  exaggerated  ;  this 
s^anptom  indicates  an  irritation  of  the  lateral  columns  of  the  cord. 

Sensory  and  motor  symptoms  gradually  develop.  The  skin  ma}'' 
become  intensely  hyperjesthesic,  and,  as  a  rule,  the  motility  of  the 
hypersesthesic  parts  is  more  or  less  impaired.  It  is  common  to  encounter 
an  incomplete  form  of  paraplegia,  or  anaesthesia  when  the  cord  or  nerve- 
roots  are  seriously  affected. 

Some  of  the  other  symptoms  of  this  disease  depend  upon  the  seat 
and  extent  of  the  lesion.  There  may  be  frequent  micturition  or  retention, 
whenever  the  A^esical  centre  of  the  cord  is  involved.  Dyspna?a  may  be 
produced  when  the  lesion  is  high  up.  Sweating  of  a  profuse  type  indi- 
cates an  impairment  of  the  vaso-motor  nerves  or  centres.  The  pupils 
may  be  irregular  from  defective  innervation  of  the  cilio-spinal  centre. 
Bed-sores  may  be  produced  on  account  of  trophic  disturbances.  It  is 
unnecessary  to  repeat  here  all  that  has  been  discussed  when  the  effects 
of  focal  lesions  of  the  cord  were  described.     (Pages  411  to  415.) 

Chronic  spinal  leptomeningitis  generally  follows  an  acute  attack. 
There  are  exceptions  to  this  rule,  but  they  are  infrequent.  The  extreme 
pain  of  the  acute  stage  usuall}^  gives  place  to  a  sense  of  dull  aching, 
soreness,  or  an  itching  and  burning  of  the  limbs.  The  "  cincture 
feeling  "  is  well  marked,  and  is  a  guide  to  the  height  of  the  lesion.  The 
intestinal,  vesical,  and  sexual  centres  of  the  cord  may  be  affected  and 
cause  marked  disturbances  of  their  functions.  We  are  apt  to  have 
constipation  or  incontinence  of  foeces,  incontinence  of  urine,  impotence 
or  priapism,  bed-sores,  etc.  The  lower  limbs  are  particularly  liable  to 
become  partially  paralyzed.     Hypersesthesia  is  also  a  common  sjanptom. 

In  the  external  variety  of  pachymeningitis  spinalis,  the  symptoms 
closely  resemble  those  of  leptomeningitis.  A  stiffness  in  the  back  when 
the  patient  rotates  the  spine  (or  when  sitting  or  standing  for  any  length 
of  time)  is  noticed  early.  The  application  of  heat,  cold,  pressure,  or  the 
negative  pole  of  a  galvanic  battery  increases  the  pain  at  the  seat  of  the 


420  LECTURES   ON  NERVOUS   DISEASES. 

morbid  changes.  Tlie  "  cincture  feeling "  is  generally  experienced 
around  the  body  at  a  level  approximating  closely  to  the  height  of  the 
lesion.  The  pain  is  apt  to  be  more  paroxysmal  than  in  leptomeningitis. 
Sometimes  the  spine  ma}'  present  evidences  of  the  primary  disease  which 
has  induced  the  morbid  changes  in  the  extra-dural  connective  tissue. 
The  neck  is  not  usually  rigid,  because  this  condition  is  infrequent  in  the 
cervical  region. 

In  the  internal  variety  of  pachymeningitis  spinalis,  the  symptoms 
run  a  more  chronic  course,  and  more  closely  resemble  those  of  spinal 
and  meningeal  tumors. 

In  the  "  hypertrophic  "  form,  the  stage  of  irritation  is  followed 
(after  a  lapse  of  a  few  months)  by  paralysis  and  atrophy  of  the  muscles. 
These  later  symptoms  are  due  to  compression  of  the  spinal  cord  or 
the  spinal  nerve-roots.  The  stage  of  irritation  is  characterized  by 
paroxysms  of  severe  neuralgic  pain  in  the  shoulders,  the  occiput,  the 
cervical  region  of  the  spine,  and  the  large  joints  of  the  upper  extremit}' . 
It  is  not  usually  atfected  by  pressure  upon  the  spinous  processes. 
Hypersesthesia  and  parjiesthesiffi  are  frequently  observed  early  in  these 
subjects.  The  skin  of  the  upper  limbs  may  show  trophic  disturbances, 
chiefly  by  desquamation,  vesicular  eruptions,  or  a  roughness  of  the 
epidermis.  The  hand  may  assume  the  typical  attitudes  depicted  by 
Charcot  and  Ross. 

Diagnosis. — The  different  forms  of  spinal  meningitis  previously 
described  are  not  always  easy  of  diagnosis.  The  best  clinicians  have 
been  misled  in  cases  where  the  autopsy  has  revealed  very  marked  lesions 
of  the  spinal  meninges.  As  a  rule,  however,  it  is  well  to  suspect  the 
existence  of  spinal  meningitis  whenever  we  encounter  a  persistent  and 
severe  pain  in  the  back  which  is  aggravated  In'  movement,  and  Avhich 
occasionally  shoots  along  the  spinal  nerves  (those  associated  with  the 
diseased  area).  Our  suspicions  are  strengthened  if  we  observe  also  a 
tendency  toward  muscular  rigidit}',  distortions  of  the  spine,  or  an 
exaggeration  of  the  spinal  reflexes,  together  with  marked  clinical 
evidences  either  of  irritation  or  impairment  of  the  motor  or  sensor}' 
functions. 

The  presence  of  marked  febrile  symptoms  at  the  onset  of  any  attack 
associated  with  spinal  symptoms  should  lead  us  to  suspect  the  develop- 
ment either  of  a  meningitis  or  a  myelitis.  It  may  be  justly  said,  how- 
ever, that  these  two  conditions  usualh'  go  hand  in  hand,  and  that  one  or 
the  other  simply  predominates..  The  existence  of  a  "girdle  pain"  or  a 
"  cincture  feeling "  is  rather  diagnostic  of  myelitis ;  as  is  also  the 
presence  of  exaggerated  reflexes,  with  bladder  and  rectal  complications, 
changes  in  the  pupils,  contractures,  or  trophic  disturbances. 

Tlie  difficulties  in  diagnosis  are  to  be  attributed  chiefly  to  the   fact 


SPINAL   MENINGITIS.  421 

that  it  makes  very  little  difference  clinically  whether  the  spinal  cord  is 
actually  diseased  or  subjected  to  pressure,  and  that  we  cannot  always 
discriminate  between  lesions  of  the  cord  and  those  which  involve  the 
spinal  nerve-roots. 

The  table  on  the  following  page  will  possibly  prove  of  value  to  the 
reader  in  making  the  diagnosis  of  the  different  types  of  spinal  meningitis 
from  each  other,  and  in  discriminating  between  them  and  other  conditions 
which  resemble  them  in  many  respects. 

Prognosis. — In  the  external  form  of  pachymeningitis  spinalis,  the 
prognosis  is  always  grave.  Recovery  is  very  rare  and  seldom  complete. 
In  the  internal  variety  recovery  is  possible. 

In  leptomeningitis  spinalis,  the  acute  variety  is  apt  to  coexist  with  a 
myelitis,  and  the  prognosis  is  grave.  It  is  especiall}-  so  if  paralysis  and 
atrophy  are  developed,  or  if  the  sphincters  are  involved.  A  bad  con- 
stitution, a  high  range  of  temperature,  dysphagia,  an  extension  to  the 
medulla,  and  extreme  youth  or  old  age  are  ail  unfavorable  to  the  patient. 
Relapses  are  ver}^  common,  even  if  the  case  progresses  favorably. 

In  the  chronic  variety,  death  is  apt  to  occur  from  cystitis,  bed-sores, 
an  acute  exacerbation  of  the  disease,  or  an  extension  to  the  medulla.  It 
is  apt  to  last  for  years,  and  to  lead  to  permanent  paralysis  and  atrophy 
of  muscles. 

Treatment. — The  cause  of  the  morbid  condition,  as  well  as  the 
symptoms  which  it  creates,  must  necessarily  modify  the  treatment  of 
each  case. 

Irrespective  of  syphilitic  origin,  some  authors  advise  calomel  by  the 
mouth.  Personally,  it  seems  to  me  a  dangerous  and  unscientific  way  of 
controlling  (?)  inflammatory  processes. 

If  syphilis  exists,  mercurial  inunctions  or  fumigation  may  be 
employed  with  benefit,  and  the  iodides  may  be  given  in  conjunction 
with  mercury.     This  subject  is  quite  fulh'  discussed  on  page  291. 

Applications  of  ice-bags,  wet-cups,  leeches,  or  the  actual  cautery 
may  be  made  to  the  spine  over  the  painful  regions. 

Bed-sores  may  be  prevented  by  extreme  care  respecting  the  patient 
and  the  bed,  and  b^^  a  change  in  posture  (preferably  upon  the  side  or 
abdomen).  Bathing  the  skin  daily  in  alcohol,  and  appl3ing  diachylon 
plaster  over  any  inflamed  spots,  may  prove  of  service  as  preventative 
measures.  Air-cushions  are  often  emploj'ed  to  remove  pressure  from 
tender  surfaces.  If  sores  actually  occur,  they  may  be  treated  by  the 
permanent  water  bath  or  by  ordinary  surgical  dressings. 

If  the  bladder  becomes  involved,  and  exhibits  incontinence,  over- 
flow or  retention,  it  is  advisable  to  introduce  a  catheter  at  regular  and 
short  intervals,  and  to  thoroughly  cleanse  the  bladder  daily  by  attaching 
the  catheter  to  the   pipe  of  a   fountain  syringe   filled  with  water  and 


422 


LECTUKES  ON  NERVOUS  DISEASES. 


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TUMOES   OF   SPINAL   CORD   AND   ITS   COVERINGS.  423 

raising  and  lowering  the  bag.  Tliis  alternately  distends  and  empties 
the  organ  and  affords  great  relief  to  many  patients.  The  patient  can 
regulate  the  pressure  by  having  a  string  which  is  attached  to  the 
fountain  run  through  a  pulley  in  the  ceiling  directlj^  over  the  side  of 
the  bed,  so  that  he  can  raise  or  lower  the  bag  without  changing  his 
posture  in  bed. 

The  pain  is  best  controlled  by  opiates  in  full  doses.  I  usually 
administer  it  b}^  the  hypodermic  method.  The  stomach  is  less  alTected 
by  so  doing,  and  you  can  control  the  dose  better  than  by  trusting  it  to 
the  patient  or  the  attendants.  If  nausea  is  created,  add  one  grain  of 
atroj^ia  to  one  ounce  of  Magendie's  solution  of  morphia  in  preparing 
the  hypodermic  solution.  Acid  should  not  be  used  in  dissolving  the 
morphia,  as  it  increases  the  danger  of  abscesses. 

Ergot  and  iodide  of  potash  are  commonly  employed  in  full  doses 
by  most  authors  who  have  written  upon  this  disease  and  mj^elitis.  I 
have  not  much  faith  in  the  beneficial  eftects  of  the  latter,  and  I  seldom 
push  ergot  to  extremes. 

As  the  patient  becomes  able  to  walk  it  is  best  to  insist  on  very 
gradual  exercise,  care  being  taken  to  avoid  over-exertion.  In  this  con- 
nection, sexual  intercourse  should  be  interdicted. 

Paralyzed  and  atrophied  muscles  may  be  subjected  to  massage, 
faradization,  galvanization,  or  static  sparks  of  a  mild  character,  I 
think  that  strong  currents  are  generally  detrimental  in  these  patients. 

Finally,  strychnia,  arsenic,  iron,  and  a  well-regulated  diet  are  of 
service  in  building  up  the  strength  during  convalescence,  or  in  prolong- 
ing the  life  of  the  patient, 

TUMOES   OF   THE   SPINAL   CORD   AND   ITS   COVERINGS. 

Within  the  substance  of  the  cord,  glioma  is  most  often  found  among 
the  tumors ;  and  sarcoma  comes  next  in  frequency.  Tubercle  and  gum- 
mata,  as  well  as  fibro-sarcoma  and  myxo-sarcoma,  may  likewise  be 
detected  at  an  autopsy.  Tumors  may  also  spring  from  the  meninges 
and  the  vertebrae  and  affect  the  spinal  cord  indirectly. 

Morbid  Anatomy.— Glioma  most  often  affects  the  cervical  and 
lumbar  enlargements.  If  extremely  vascular  (as  it  sometimes  is)  the 
tumor  may  be  infiltrated  with  blood  and  contain  blood-cysts.  It 
in-obably  starts  from  the  neuroglia.  Mixed  varieties  of  glioma  are 
sometimes  found  in  the  substance  of  the  cord  (chiefly  glio-sarcomata). 

In  the  meninges  of  the  cord,  we  may  encounter  all  the  varieties  of 
tumors  mentioned  excepting  glioma;  and,  in  addition,  carcinoma, 
psammoma,  parasitic  growths,  fibromata,  and  myxomata. 

The  bones  of  the  vertehi-al  cohnnn  and  their  periosteum  may  be  the 
starting  point  of  intra-spinal  growths.     These  may  compress  the  cord. 


424  LECTURES   ON  NERVOUS  DISEASES. 

Finally,  aneurisms  of  the  spinal  arteries  or  of  the  thoracic  or 
abdominal  aorta  may  interfere  with  tlie  functions  of  the  cord.  The  latter 
can  only  do  so  b}'  first  causing  absorption  of  the  vertebrae. 

Etiology. — Wounds,  injuries,  and  tlie  results  of  tubercular,  cancerous, 
and  sypliiliLic  cachexite  are  the  onl}-  definitely  known  causes  of  these 
morbid  growths. 

Symptoms — Tumors  of  the  spinal  canal  cause  symptoms  either  by 
irritation  or  compression  of  the  cord  or  the  spinal  nerve-roots  or  by 
inducing  changes  in  the  bones.  Even  when  of  large  size  they  may 
produce  no  symptoms.  In  some  cases  we  ma}-  encounter  all  the  clinical 
evidences  of  a  myelitis,  or  of  spinal  meningitis.  The  general  remarks 
made  in  reference  to  focal  lesions  of  the  cord  (pages  411  to  415)  are 
applicable  to  spinal  tumors. 

Diagnosis. — Although  it  is  often  impossible  to  recognize  a  spinal 
tumor  and  its  seat  during  life  with  certainty,  there  are  some  symptoms 
which  should  lead  to  a  suspicion  of  this  condition.  These  comprise : 
(1)  an  excess  of  motor  paralysis  on  one  side  of  the  bod}"  over  that 
observed  on  the  other,  with  an  excess  of  anaesthesia  on  the  side  where 
motility  is  least  affected ;  (2)  a  clinical  history  which  would  lead  to  the 
suspicion  of  tubercle,  cancer,  or  syphilis  in  the  patient;  and  (3)  the  long 
duration  of  the  disease  (usually  from  six  months  to  several  j^ears)  and 
the  gradual  development  of  the  spinal  sj^mptoms.  Moreover,  the  ability' 
on  the  part  of  the  patient  to  recognize  with  closed  eyes  the  position  of 
the  limb  during  passive  movements  (muscular  sense)  is  apt  to  be  more 
affected  on  one  side  (that  corresponding  to  the  tumor)  than  on  the 
other. 

When  more  than  one  tumor  exists,  the  diagnosis  is  even  more 
uncertain  than  if  the  growth  were  single.  It  might  then  simulate 
multiple  spinal  sclerosis.  I  lately  treated  a  case  of  this  description. 
By  a  careful  study  of  the  s^-mptoms  I  was  enabled  to  recognize  during 
life  a  multiple  lesion  of  the  cord  and  the  seat  of  the  morbid  processes 
with  some  exactness,  and  I  suspected  either  multiple  sclerosis  or  multiple 
tumor.  The  autopsy  confirmed  the  latter  view,  as  sarcomata  of  the 
meninges  were  discovered. 

Prognosis. — This  depends  upon  the  nature  of  the  growth.  If  it  is 
sj'philitic,  recovery  under  the  treatment  indicated  on  page  291  may  be 
expected,  provided  the  spinal  cord  has  sustained  no  permanent  injury 
from  compression.  Tubercle  may,  in  exceptional  cases,  be  recovered 
from.     As  a  rule,  however,  spinal  tumors  are  fatal. 

Treatment. — Iodide  of  potash,  arsenic,  cod-liver  oil,  phosphatic 
salts,  etc.,  may  be  employed  as  symptoms  arise  which  seem  to  demand 
them,  unless  the  case  be  clearly  of  syphilitic  origin.  In  the  latter 
form  the  most  active  specific  treatment  is  indicated. 


SPINAL   HEMOKRHAGE.  425 

SPINAL   HEMORRHAGE. 

Blood  is  rarely  extra v.isated  into  the  substance  of  tlie  spinal  cord. 

It  is  generally  poured  out  into  the  spinal  meninges.     We  can  therefore 

divide  spinal  hemorrhage   into  the  intra-meduUary  variety  or  "  spinal 

apoplexy,"  and  the  extra-medullary  variety,  or  "  meningeal  hemorrhage." 

SPINAL   APOPLEXY. 
{Hsematomyelia.) 
Etiology. — This  condition  is  somewhat  rare.     It  may  occur  from 
changes   in  the   coats    of    the    blood-vessels   or   from   excessive   blood- 
pressure.     Probably  the  latter  cause  is  not  alone  sufficient  to  induce  it 
in  health. 

Morbid  Anatomy. — We  encounter  intra-meduUary  hemorrhage  in 
connection  with  giiomatous  tumors,  acute  myelitis,  and  traumatisms. 
The  clot  is  usually  small  in  size,  seldom  exceeding  that  of  an  almond. 

In  exceptional  cases,  the  blood  may  escape  through  the  pia  into  the 
subarachnoidean  cavity. 

The  age  of  the  clot  will  modifj^  its  appearances  at  an  autopsy.  If 
recent  it  will  be  red  or  blackish-red.  Older  clots  become  brown  or 
yellow  in  color.  If  sufficient  time  has  elapsed  to  allow  of  still  further 
changes,  the  clot  may  be  found  to  be  encapsulated  by  a  fibrous  deposit, 
or  possibly  an  apoplectic  C3-st  or  a  pigmented  cicatrix  ma}'  be  all  that 
remains  of  the  original  lesion. 

Symptoms. — These  depend  upon  the  seat  and  extent  of  the  lesion. 
As  a  rule,  the  patient  is  attacked  with  sudden  paraplegia,  accompanied 
by  severe  pain  in  the  back.  The  pain  usually  subsides  within  twenty- 
four  hours.  Occasionall}^,  the  symptoms  will  indicate  a  unilateral  lesion 
of  the  cord.  (Fig.  6t.)  Again,  the  effects  of  disease  confined  to  the 
posterior  or  anterior  horns  will  be  evidenced  at  the  onset. 

Prodromata  are  very  infrequently  observed.  Consciousness  is  not 
lost  except  when  the  lesion  is  situated  near  the  medulla.  A  slight  fever 
is  apt  to  follow  the  attack  after  a  lapse  of  some  hours.  A  high  range  of 
temperature  only  occurs  as  the  result  of  complications,  such  as  cystitis, 
bed-sores,  etc. 

The  paralysis  may  be  of  the  type  of  monoplegia,  hemiplegia,  or 
paraplegia. 

The  sensory  functions  ma}^  be  disturbed,  causing  anaesthesia,  anal- 
gesia, h3'periBsthesia,  parjesthesioe,  etc. 

The  bladder  and  rectum  may  be  affected. 

The  reflexes  may  be  abolished  or  exaggerated. 

Vaso-motor  and  trophic  disturbances  have  been  observed,  and  also 
haematuria  and  albuminuria. 


42G 


LECTURES   ON   NERVOUS  DISEASES. 


The  effects  of  focal  lesions  of  the  cord  at  different  levels  may  be 
studied  in  tliis  connection  with  benefit.     (Pages  411  to  415.) 

Diagnosis. — Some  of  the  more  important  symptoms  of  this  affection 
can  be  contrasted  with  those  of  other  spinal  diseases  (which  closely 
simulate  it)  as  follow : — 


SPINAL 
MENIXGEAti 
. .  HEMOKKIIAGE. 

{Hamatomyelia.)  ^HoematorrhachU) 


SPINAL 
APOPLEXY. 


Rapidity 
Onset 


Fever. 


j  Rapid.    May   be 
I   instantaneous. 


I  Rapid  or  instan- 
I    taneous. 


POLIOMYELITLS 

ANTEKIOR 

ACUTA. 


MYELITIS. 


1  Never    instanta- 
I   neous. 


C  Absent  at  onset, 
■i  Occurs  on  second 
L  or  third  day. 


Pain. 


Hyperjesthesia 


Anesthesia  , 


{ 


Absent  at  onset. 
(Jecurs  on  second 
or  third  day. 


[Frecedes 


r  ralysis. 

rSevereinbaefcat    r^sj^rked  in  bacfc  n 
J   onset  and  sradu-  J    ^.^^i   n,,,,^,    ^nd  .  '  ^.„  „„,„ 
<(  ally  subsides.       ^    are  of  consider-    f'^'' -P"*"' 
\Xot   marked    in    I    able  duration.      I J 
1.  limbs.  j  ^  I 

May  be  wanting.     Generally  present.  !  Absent. 


Mav    exist    in   f  Usually     irnper-  -i 
parts    below  j    fectly     devel-    ' 


lesion.  Appears   |    oped     and    ap- 
at  onset.  L  pears  late. 


s- Absent. 


„  „    „   fOccur    at    onset 

Contracture  J    ^j  ^^  ^11)  as  a 

,  L  rule. 


•  and  Bpasji. 


Sphincters     of  t 
Bladder    and    UOften  paralyzed. 
RECTU-M J 

(   veloped. 

j  C  Occurs      rapidly  "1 
j      only  in   those    I 
Atrophy     of  j    muscles   con- 

MuscLES 1    nected  with  a/ 

I  fected    spinal    i 


Are  strongly  di- 
agnostic. 

Unaffected  until 
late  in  the  dis- 
ease. 


Absent. 


Normal. 


Not  developed.      Not  develoi>ed. 


Never  instanta- 
neous. Compar- 
atively slow,  as 
a  rule. 


f  Mav  be  absent. 
•P""  -j  Is  ■  generally 
L  marked. 


Not  prominent 
as  a  symptom. 

May  be  totally 
absent. 


Not  marked. 


fAn  early  sign, 
■i  and  is  generally 
L  well  marked. 


J  Not  usually  very 
I   prominent. 

<  Peculiarly  liable 
I   to  be  affected. 

^  E.xtremely  com- 
(   mon. 


}■  May 


Electrical 
Tests 


Prognosis  . 


L  segments. 

'Reaction   of  de-  ~| 
general i  o n    in 
atrophied   mus-    | 
cles    associated    y  Mav  be  normal, 
with     affected 
segments     of 
cord. 

rOften  fatal.    Re-  ^  „        ,  ^ 
IJ    coverv     always    Lfomplete  recov- 
1  incomplete.  J    ery  is  possible. 


fOccurs  rapidly  in  1 
•i    all  the   />«i-a-  piaynotexist. 
L  lyzed  muscles. 


{Reaction  of  de- 
generation in 
all  par  a  1  y  ze  d 
muscles. 


\  Rarely  fatal 


TMav  be  normal, 
A  exaggerated,  or 
L  abolished. 


i  Generally      un- 
'   favorable. 


Prognosis. — 'The  situation  of  the  clot  modifies  the  prognosis,  as  well 
as  the  amount  of  blood  which  is  extravasated  into  the  substance  of  the 
cord.  Hemorrhages  into  the  dorsal  segments  cause  less  serious  symp- 
toms than  if  present  in  the  cervical  segments  (where  the  respiration  may 
be  disturbed  by  interference  with  the  phrenic  nerve),  or  in  the  lumbar 
segments  (where  the  centres  for  the  vesical  and  rectal  sphincters  are 
probably  situated).     The  rapid  development  of  bed-sores  is  an  unfavor- 


SPINAL   MENINGEAL   HEMORRHAGE.  427 

able  sign.     In  any  case,  a'complete  recovery  is  impossible,  and  a  long 
duration  of  life  improbable. 

Treatment. — To  arrest  danger  to  tiie  patient  from  a  further  escape 
of  blood,  ice-bags  should  be  applied  to  the  spine  as  soon  after  an  attack 
as  possible,  and  large  doses  of  ergotine  should  be  given  by  the  mouth  or 
hypodermicall3^  The  patient  should  be  placed  in  a  horizontal  posture, 
and  absolute  rest  and  quiet  should  be  insisted  upon.  All  undue  excite- 
ment should  be  carefully  guarded  against.  The  subsequent  treatment 
does  not  diiier  materially  from  that  already  recommended  for  myelitis. 

SPINAL   MENINGEAL   HEMORRHAGE. 
{Hsematorrhachis.) 

This  morbid  condition  is  not  commonly  encountered.  It  is  more 
frequent  among  males  than  females.  It  mviy  be  secondary  to  a  spinal 
apoplexy  which  has  perforated  the  pia,  or  to  an  aneurism. 

Etiology. — No  cause  can  be  discovered  in  some  cases.  In  others,  a 
history  of  traumatism,  tuberculosis  or  cancer  of  the  spine,  violent 
excitement,  suppressed  menstruation,  cardiac  hypertrophy,  attacks  of 
spasmodic  diseases,  purpura,  a  hemorrhagic  diathesis,  some  infectious 
disease,  or  the  presence  of  an  aneurism  (which  has  at  last  burst  into  the 
spinal  canal),  may  be  detected.  It  ma}^  occur  in  the  infant  from  the 
use  of  forceps.  A  cerebral  hemorrhage  has  been  known  to  be  suf- 
liciently  severe  to  flow  into  the  spinal  canal. 

Symptoms. — These  are  dependent  upon  the  extent  and  seat  of  the 
hemorrhage.  They  are  largel}^  due  to  irritation  or  compression  of  the 
spinal  nerve-roots  at  first,  and  possiblj^,  later  on,  to  spinal  compression 
or  myelitis. 

The  character  of  the  onset  depends  to  a  great  extent  upon  the 
rapidity  of  the  effusion.  A  large  clot  will  cause  at  once  very  severe 
shooting  pains  in  the  back  and  the  limbs,  with  more  or  less  muscular 
twitchings,  cramps,  spasms  and  rigidity. 

The  onset  is  unaccompanied  by  fever;  and  the  paralysis  and  antes- 
thesia  are  not  very  pronounced  at  first.  On  the  second  or  third  day 
reactive  fever  sets  in  to  a  moderate  extent. 

There  is  apt  to  be  a  "  cincture  feeling  "  around  the  chest  or  abdomen. 

If  the  bladder  or  rectum  show  any  impairment,  or  when  bed-sores 
occur,  it  indicates  that  the  spinal  cord  is  compressed. 

Whenever  the  nerve-roots  become  seriously  impaired  by  pressure 
of  the  clot,  the  functions  of  motion  or  sensation,  as  well  as  the  spinal 
reflexes  and  the  electrical  tests  of  nerves  and  muscles  begin  to  show  a 
pi'ogressive  deterioration. 

Prognosis. This   disease   lasts   from   two    weeks   to  an   indefinite 

period.     It  is  possible  for  death  to  occur  from  shock,  soon  after  the 


428  LECTURES   ON   NERVOUS   DISEASES. 

onset,  provided  the  clot  be  near  the  medulla.  Spinal  hemorrhage  maj' 
induce  a  complicating  meningitis  ;  and  the  extension  of  this  inflammation 
to  the  medulla  may  cause  death.  Permanent  paralysis  and  atrophy  of 
muscles  may  be  induced  by  pressure  upon  tlie  anterii^r  nerve-roots, 
although  the  spinal  cord  may  have  entirely  escaped  injury. 

The  published  records  of  these  cases  go  to  show  that  quite  a  large 
percentage  tend  to  make  a  recovery  without  any  ver3'  serious  impairment 
of  motion  or  sensation. 

Treatment. — This  is  similar  to  that  given  for  spinal  apoplexy. 

MYELITIS. 

Inflammation  of  the  substance  of  the  spinal  cord  has  been  partially 
studied  already  under  the  heads  of  two  systematic  spinal  diseases,  viz. : 
poliomyelitis  anterior,  and  central  myelitis. 

We  now  approach  the  consideration  of  structural  changes  in  the 
cord  of  an  inflammatory  type  which  assumes  the  character  of  a  focal  or 
"non-systematic  "  spinal  disease. 

We  shall  discuss  this  morbid  condition  as  of  two  varieties,  the  acute 
and  chronic. 

ACUTE   MYELITIS. 

This  disease  may  be  primary  or  secondar}^  It  is  comparatively  a 
rare  affection  ;  more  frequent  in  males  than  in  females,  and  is  generally' 
observed  during  middle  life. 

Etiology.— The  causes  of  this  disease  vary  with  its  type;  although 
a  predisposition  to  it  may  be  engendered  by  excesses  in  alcohol,  bad 
hygiene,  overwork,  venereal  excesses,  and  exposure  to  dampness. 

The  primary  variety  may  be  developed  as  the  result  of  rheumatism, 
traumatism  to  the  spine,  severe  emotional  excitement  and  certain  poisons. 
Among  the  latter  causes,  lead,  arsenic,  mercury,  phosphorus,  alcohol, 
and  carbonic  oxide  have  been  known  to  induce  it.  Some  of  these 
poisons  ma^^  be  taken  into  the  system  while  following  certain  manu- 
facturing pursuits. 

The  secondary  variety  may  be  induced  by  diseases  of  the  vertebrai 
and  the  spinal  meninges;  either  by  extension  of  inflammatory  processes 
or  as  the  result  of  compression  of  the  cord.  Again,  it  has  been  known 
to  follow  pneumonia,  phthisis,  syphilis,  diphtheria,  pj-aemia,  the  eruptive 
fevers,  and  malarial  poisoning. 

Morbid  Anatomy.  —  Myelitis  of  the  acute  form  most  commonly 
attacks  the  dorsal  segments ;  occasionall}-  the  cervical  and  lumbar 
enlargements  of  the  cord.  The  extent  and  seat  of  the  inflammation 
varies.  It  may  attack  the  central  gray  matter  (central  myelitis);  again, 
it  may  traverse  the  entire  spinal  seginmit  {transverse  myelitis)',  finalh', 


ACUTE  MYELITIS.  429 

it  may  be  distinctl}'  circumscribed  and  confined  to  one  lateral  half  of  the 
cord  (cii'cumscribed  myeMtiti). 

A  very  rare  condition,  known  as  '•'■  periinyelitis^''  or  '■'■myelo- 
meningitis (in  which  only  the  periphery  of  the  cord  is  inflamed)  has  been 
observed. 

The  appearance  of  spots  of  myelitis  must  not  be  confounded  with 
post-mortem  changes  which  are  commonly  detected  during  the  warm 
months  in  subjects  which  have  been  kept  some  time. 

When  myelitis  is  present,  we  may  encounter  the  characteristic 
appearances  of  red,  white,  or  yellow  softening.  These  have  been 
described  in  connection  with  the  brain  (page  317). 

The  formation  of  a  distinct  abscess  of  the  cord  is  sometimes 
observed  in  myelitis  of  the  acute  form.  It  is  most  often  found  in 
pyanuic  and  traiimatic  cases. 

The  meninges,  especially  the  pia,  are  generallj^  more  or  less  reddened, 
softened,  and  infiltrated  with  pus.  The  nerve-roots  may  be  markedly 
swollen  and  appear  redder  than  normal.  Finally,  evidences  of  ascending 
or  descending  spinal  degeneration  (see  Fig.  92)  are  generally'  to  be 
detected. 

Symptoms. — The  onset  of  an  acute  mjelitis  may  or  may  not  be 
jM-eceded  by  prodromata.  If  so,  they  are  poorly  defined  and  are  those 
of  slight  febrile  disturbance. 

The  o??se<  may  be  accompanied  b}- convulsions  in  children;  and,  in 
adults,  by  a  chill  and  marked  fever. 

Within  a  short  space  of  time  the  patient  begins  to  notice  abnormal 
sensory  symptoms,  such  as  pain  in  the  back,  a  cincture  feeling  around 
the  chest  or  abdomen,  formication  and  shooting  pains  in  the  liml:is, 
pains  in  the  joints  or  cardialgia.  The  pain  in  the  back  is  not  increased 
by  movement,  unless  a  spinal  meningitis  coexists. 

The  muscles  may  exhibit  twitchings  or  temporary  contractures 
early.  The  bladder  may  be  affected  almost  from  the  onset ;  causing 
either  retention,  overflow,  or  incontinence  of  urine. 

Later  in  the  disease,  paralysis  of  the  muscles  of  a  complete  or 
partial  character  develops.  Complete  anaesthesia  may  be  observed  in 
other  parts. 

The  muscles  begin  to  waste  rapidly  whenever  the  anterior  horns  of 
the  spinal  gray  matter  are  attacked  ;  and  the  "reaction  of  degeneration  " 
is  then  developed  in  the  nerves  and  muscles  associated  with  the  spinal 
segments  thus  afiected. 

If  the  muscles  of  the  abdomen  or  chest  are  paralyzed,  respiration 
l)ecomes  markedly  interfered  with,  and  slight  pulmonary  complications 
become  a  source  of  danger  to  the  patient.  Asphyxia  develops  suddenly 
when  the  phrenic  nerve-roots  are  attacked. 


430  LECTURES   ON   NERVOUS   DISEASES. 

In  some  cases  delayed  sen.sation  (page  398)  is  observed.  In  rare 
instances,  circumscribed  stimulation  of  tlie  skin,  as  in  tlie  case  of  a  pin- 
thrust,  is  followed  by  a  vibration  of  the  limb.  This  is  known  as 
"  dijsaenthesiay 

The  vaao-molor  nerves  generally  give  clinical  evidence  of  their 
imi)airment  quite  early  in  the  disease.  The  paralyzed  limb  may  cease 
to  perspire.  The  joints  may  swell  from  oedema,  and  become  cold  and 
peculiarly  pale.  Eruptions  may  develop,  usually  of  the  vesicular  type. 
Over  the  bony  points  which  sustain  the  weight  of  the  patient,  the  skin 
is  peculiarly  liable  to  become  reddened,  and  to  undergo  a  rapid  form  of 
gangrenous  destruction.  We  encounter  bed-sores  of  this  type  chiefly  in 
the  region  of  the  sacrum,  and  over  the  trochanters,  malleoli,  and  the  os 
calcis. 

Cerebral  symptoms  are  generally  absent.  In  rare  cases,  atrophy  of 
the  optic  nerve  has  been  observed. 

The  urine  may  become  ammoniacal,  bloody,  albuminous,  and  sac- 
charine. Indications  for  regular  catheterism  are  often  clearly  pro- 
nounced. Involuntary  evacuations  of  the  bowels  may  follow  a  paralysis 
of  the  sphincters. 

The  condition  of  the  reflexes  varies  with  the  seat  and  extent  of  the 
lesion.  If  the  lateral  column  is  alone  affected,  they  will  be  exaggerated. 
If  the  "reflex  arc  "(Fig.  34)  is  injured  anywhere  in  its  course,  they 
will  be  decreased  or  abolished. 

Diagnosis. — Acute  myelitis  is  apt  to  be  confounded  with  spinal 
meningitis,  spinal  apoplexy,  spinal  meningeal  hemorrhage,  hysterical 
paralysis,  and  multiple  neuritis. 

From  the  first  three  of  these  diseases,  the  distinguishing  points  are 
clearly  shown  in  a  diagnostic  table  on  page  42G. 

From  true  hysterical  paralysis,  without  organic  spinal  changes, 
acute  myelitis  is  to  be  told  by  its  rapid  course,  its  febrile  sj-mptoms,  its 
bladder  and  rectal  complications,  its  trophic  disturbances,  and  the  sex 
affected. 

From  multiple  neuritis^  my q\\{\^  is  to  be  differentiated  in  many  cases 
by  the  absence  of  severe  pains  in  the  limbs,  an  imperfect  history  of 
excess  in  alcoliol,  the  pain  in  the  back,  and  the  retention  of  normal 
electrical  formulae,  both  of  nerves  and  muscles.  In  a  few  cases,  the 
diagnosis  is  difficult.  While  it  is  not  always  easy  to  make  the  distinc- 
tion, it  must  be  remembered  that  bed-sores  and  a  disturbance  of  the 
bladder  and  rectum  are  peculiarly  characteristic  of  myelitis. 

Prognosis. — If  the  myelitis  is  not  of  the  hemorrhagic  variety, 
the  duration  of  the  acute  form  is  usually  from  one  to  several  weeks. 
The  patient  may  die  of  ammoniaemia,  septicjvmia.  pyaemia,  exhaustion, 
paralysis    of  the    respirator}'  or  cardiac   centres,   or  some    pulmonary 


CHRONIC  MYELITIS.  431 

complication  (chief!}'  pneumonia).  Some  patients  pass  into  a  subacute 
or  chronic  variety  of  myelitis,  A  few  are  said  to  have  recovered 
completely. 

Treatment. — The  steps  indicated  in  connection  with  the  treatment 
of  spinal  meningitis  are  applicable  to  that  of  myelitis. 

CHRONIC   MYELITIS. 

Under  this  head  some  authors  place  all  inflammatory  conditions  of 
the  substance  of  the  spinal  cord  which  are  focal  in  type,  run  a  pro- 
tracted course,  and  are  unattended  with  febrile  symptoms.  Some  of  the 
'•  systematic  "  diseases  already  described  are  but  special  forms  of  chronic 
mj'elitis  ;  as,  for  example,  primary  lateral  sclerosis,  locomotor  ataxia, 
amyotrophic  lateral  sclerosis,  poliom3'elitis  anterior  acuta,  etc. 

Etiology. — A  congenital  or  acquired  hereditary  predisposition  to 
this  form  of  myelitis  is  more  pronounced  than  in  the  acute  variety. 
The  exciting  causes  are  similar  to  those  of  the  acute  form  of  the  disease. 

Morbid  Anatomy. — The  eye  will  usually  detect  a  flattening  or 
depression  of  the  spinal  cord,  with  an  unnatural  firmness  of  its  substance, 
at  the  seat  of  the  disease.  The  pia  ma^^  bo  adherent  over  the  diseased 
area ;  and  it,  as  was  the  dura,  may  be  markedly  thickened.  In 
exceptional  cases  softening  of  the  cord  is  observed  ;  possibly,  also,  the 
formation  of  cavities  in  its  substance  (syringomyelia)  may  be  detected. 

The  microscope  will  usually  show  an  increase  of  Deiter's  cells, 
which  are  often  enlarged  and  present  numerous  nuclei ;  a  marked 
increase  of  the  neuroglia ;  a  thickening  of  the  coats  of  the  blood- 
vessels ;  a  dilatation  of  the  lymphatic  sheaths  of  the  blood-vessels ;  an 
enlargement  of  the  axis-cylinders  (chiefly  at  the  periphery  of  the  lesion); 
a  disappearance  of  the  medullary  sheaths  ;  and  the  presence  of  granulo- 
fatty  cells. 

Chronic  myelitis  inay  in  exceptional  cases  be  confined  to  one  lateral 
half  of  the  cord.  It  moi*e  often  tends  to  spread  transversely  to  both 
lateral  halves.     It  may  also  assume  a  multiple  form. 

The  abdominal  and  thoracic  viscera  may  exhibit  evidence  of  existing 
'Complications  of  myelitis. 

Symptoms. — These  are  modified  somewhat  by  the  seat  and  extent 
of  the  lesion, — a  statement  which  is  true  of  all  focal  spinal  lesions.  In 
a  general  way,  they  resemble  those  of  the  acute  variety  of  myelitis,  save 
in  the  foct  that  their  approach  is  more  gradual  and  unattended  with 
fever. 

Hypersesthesia,  numbness,  formication,  and  occasional  severe  pains 
in  the  limbs  are  commonly  observed.  These  are  followed  or  accom- 
panied by  a  steadily  increasing  weakness  of  the  lower  limbs,  usuall}' 
associated  with  imperfect  micturition  and  defecation. 


432  LECTURES   ON   NERVOUS   DISEASES. 

Paraple.iria  is  more  frequent  than  unilateral  paralysis  in  this  disease. 
Whenever  the  lateral  column  of  the  cord  is  attacked,  the  gait  of  spastic 
paralysis  may  be  induced  (p.  163).  We  are  particularly  apt  under  these 
circumstances  to  encounter,  in  addition  to  the  progressive  paresis  of  the 
legs,  contracture,  muscular  spasms,  and  exaggeration  of  the  tendon 
reflexes. 

The  later  symptoms  of  this  affection  are  similar  to  those  of  the 
acute  form  already  described.  In  some  instances,  "bulbar  symptoms" 
(p.  384)  may  be  added  to  those  already  mentioned. 

Diagnosis.— All  forms  of  paraplegia  must  be  differentiated  from 
each  other.  Whenever  this  symptom  is  clinically  encountered,  the 
differential  tables  given  on  pp.  422  and  426  will  assist  the  reader  in  doing 
so  ;  and  the  light  thrown  upon  the  symptomatology  of  diseases  of  the 
spinal  cord  in  the  first  section,  together  with  the  general  remarks  on 
"focal"  spinal  lesions  will  aid  in  localizing  the  exact  seat  of  the  lesion 
which  has  induced  paralysis. 

It  is  very  important  in  all  focal  spinal  lesions  (1)  that  the  exact 
limits  of  both  the  motor  and  sensory  paralyses  be  accurately  mapped  out 
in  each  individual  case ;  and  (2)  that  the  vertical  extent  of  the  lesion  be 
determined  by  testing  each  of  the  spinal  reflexes.  This  can  be  done  by 
the  methods  already  described  in  Section  II  of  this  work.  Those  only 
are  abolished  which  depend  upon  a  reflex  arc  in  the  diseased  segments. 
If  a  bed-sore  develops  it  is  clinical  evidence,  as  a  rule,  that  the  nerves 
which  sup{)ly  that  particular  area  of  skin  are  involved  directly  in  the 
spinal  lesion.. 

Prognosis. — Syphilitic  cases  may  make  a  complete  recovery;  pro- 
vided treatment  be  begun  before  spastic  symptoms  become  developed. 
The  course  of  the  other  varieties  of  chronic  myelitis  is  very  protracted 
(often  ten  to  twent}^  years),  but  is  usually  fatal. 

Treatment. — The  treatment  suggested  for  spinal  meningitis  is 
applicable  to  this  disease.  Erb  extols  the  effects  of  the  "cold-water 
cure  "  in  Ziemssen's  Encyclopedia,  and  gives  some  directions  for  its  use. 
I  have  never  tried  it  personally. 

If  spastic  symptoms  are  prominent,  ergot  and  the  nitrate  of  silver 
act  better  than  strychnia,  in  my  experience.  When  the  paralyzed 
muscles  are  relaxed  and  flaccid,  strychnia,  iron,  arsenic,  phosphorus  and 
quinine  are  of  benefit. 

I  have  obtained  very  beneficial  results  in  several  cases  by  the 
withdrawal  of  heavj'  static  sparks  from  the  spine  and  the  paralyzed 
muscles.  This  treatment  certainlj'  surpasses  any  other  form  of  electrical 
application.  The  machine  must  have  large  plates  to  generate  sufiicient 
quantity  to  yield  good  results. 


SYRINGOMYELIA  AND   HYDEOMYELIA. 


433 


CL 


SYEINGOMYELIA    AND    HYDEOMYELIA. 

Cavities  in  the  substance  of  the  spinal  cord  may  exist  either  as  a 
congenital  or  acquired  condition.  Their  extent,  situation,  and  contour 
vary  in  different  cases.  They  usually  contain  a  serous  or  hemorrhagic 
fluid,  and  occasionally  a  hj^aline  material. 

These  cavities  may  be  single  or  multiple.  They  are  most  common  in 
the  posterior  white  columns  of  the  cervical  and  dorsal  segments  of  the 
cord.  They  may  be  totally  independent  of  the  central  canal  of  the  cord, 
but  they  usually  communicate  with  it.  The  anterior  horns  are  occasion- 
all}^  found  to  be  the  seat  of  such  cavities. 

Morbid  Anatomy. — The  wall  of  these  cavities 
is  generally  composed  of  a  firm  fibrous  tissue 
(which  is  apt  to  be  friable  and  highly  vascular), 
or  of  myxomatous  tissue.  Its  inner  surface  may 
or  may  not  be  lined  with  epithelial  cells  of  the 
cylindrical  variety'. 

Acquired  cavities  may  result  from  the  soften- 
ing and  degeneration  of  clots  or  of  sj)inal  tumors 
(chiefly  glioma),  and  from  spinal  compression. 
Chronic  myelitis  may  possibly  induce  cavities 
within  the  cord.  Meningeal  adhesions  have  been 
considered  by  some  authors  as  a  possible  factor 
in  their  development. 

Symptoms. — Large  cavities  in  the  cord  may 
exist  without  causing  any  symptoms  during  life. 
If  they  are  created  by  the  morbid  conditions 
mentioned  above,  the  sj^mptoms  will  be  those  of 
the  exciting  cause. 

The  situation  of  these  spinal  cavities  being, 
as  a  rule,  confined  to  the  anterior  horns,  the 
central  gray  matter  and  the  posterior  columns 
of  the  cord  would  naturally  suggest  the  co- 
existence during  life  of  interference  with  the 
sensory,  vaso-motor,  and  trophic  functions  of  the 

spinal  segments  involved,  as  well  as  more  or  less  atrophy  of  the  muscles, 
and  possibly  motor  paralysis.  The  reported  cases,  where  post-mortem 
observation  has  confirmed  the  diagnosis,  seem  to  sustain  such  a 
conclusion. 

Among  the  ahnormal  sensory  pheiwiuena  noted  by  various  observers, 
we  find  the  following  mentioned :  Analgesia,  an  imperfect  perception 
of  varying  degrees  of  temperature,  and  occasionally  an.'^sthesia  and  im- 
perfect localization  of  touch-impressions.     The  seat  of  these  abnormal 

28 


c/ 


Fig.  120. — Cavities  within  thb 
Substance  of  the  Spinal 
Cord,  CONSTITUTING  the  Con- 
dition KNOWN  AS  "SykINGO- 
MVELiA."  a,  i.  Cervical  cord  ; 
c,  dorsal  cord  ;  d,  e,  lumbar  cord. 


434  LECTURES   ON   NERVOUS   DISEASES. 

sensory  phenomena  depends  upon  the  spinal  segments  attacked.  (See 
tables  on  pages  411  and  415.) 

The  abnormal  trophic  or  vaso-motor  phenomena  ma}^  comprise  any  or 
all  of  the  following  conditions  :  Eruptions  (chiefly  of  the  bullous  tj^pe), 
defective  secretion  of  perspiration  in  some  localized  form,  abscesses  or 
intractable  ulceration,  fragility  or  atrophy  of  bones,  lowering  of  the 
temperature  of  some  parts,  cyanosis,  etc. 

The  abnormal  muscular  phenomena  may  comprise  all  the  symptoms 
enumerated  when  describing  the  clinical  history  of  poliomyelitis. 

Diagnosis. — This  disease  may  be  confounded  during  life  with  mul- 
tiple neuritis,  amyotrophic  lateral  sclerosis,  poliomyelitis,  multiple 
sclerosis,  and  spinal  tumors  outside  of  the  cord. 

From  multiple  neuritis^  it  is  told  by  the  fact  that  impressions  of 
touch,  temperature,  and  pain  are  not  equally  and  simultaneously  im- 
paired, as  they  are  when  a  nerve-trunk  is  undergoing  extensive  degenera- 
tion. The  history  of  the  patient  might  also  exclude  the  exciting  causes 
of  neuritis. 

From  amyotrophic  lateral  sclerosis,  this  affection  is  told  by  its  being, 
as  a  rule^  a  unilateral  spinal  affection,  and  by  the  absence  of  the  peculiar 
rigidity  of  the  muscles  and  the  characteristic  deformity  of  amyotrophic 
spinal  sclerosis.  Moreover,  the  duration  of  life  is  much  longer  in 
syringomyelia. 

From  poliomyelitis  anterior,  it  differs  in  that  sensor}-  sj-mptoms 
generally  coexist  with  paralysis  and  atrophy,  and  also  in  that  the  vaso- 
motor and  trophic  disturbances  are  quite  marked. 

From  multiple  sjnnal  sclerosis,  it  may  be  told  by  the  absence  of 
tremor,  and  the  limited  number  of  spinal  segments  involved  in  sj'ringo- 
myelia. 

From  spinal  tumors,  pressing  upon  one  lateral  half  of  the  cord,  this 
disease  is  to  be  distinguished  chiefly  b}^  the  absence  of  all  sj-mptoms 
pointing  to  an  implication  of  the  vertebrae. 

Prognosis. — Syringomyelia  seems  to  follow  a  somewhat  uncertain 
course.  It  may  progress  slowly,  or  become  stationary  for  long  periods 
of  time.     Occasionally  it  causes  a  sudden  fatal  termination. 

FUNCTIONAL   DISEASES    OF   THE    SPINAL   CORD. 

In  a  preceding  table  (p.  350)  we  have  included  under  this  head  the 
conditions  of  spinal  irritation,  functional  paraplegia,  spinal  neurasthenia, 
writers'  cramp  or  paralysis,  and  tetany-. 

Some  of  these  will  be  discussed  under  the  general  head  of  functional 
nervous  disease,  to  whose  special  consideration  the  sixth  section  of  this 
work  will  be  devoted.  Others  demand  some  passing  notice  in  this 
section. 


SPINAL   IRRITATION.  435 

SPINAL   IRRITATION. 

(Anaemia  of  the  Posterior   Columns.) 

Notwithstanding  th6  opinions  of  man >' writers  to  tlie  contrary,  it  is 
questionable  to  ni}-  mind  wliether  it  is  proper  to  regard  tliis  condition  as 
a  special  form  of  disease.  The  sjanptoms  which  are  generall3'  enumer- 
ated under  this  head  are  very  often  nothing  more  than  manifestations  of 
the  hysterical  or  neurasthenic  states.  It  is  probably  a  i)urely  functional 
derangement,  and  affects  j'oung  adults  (from  fifteen  to  thirtj'-five  jears 
of  age),  chiefly  of  the  female  sex. 

Etiology. — For  information  on  this  subject,  I  would  refer  the  reader 
to  my  remarks  relating  to  the  causes  of  neurasthenia  and  hysteria. 

Symptoms. — Pain  in  the  region  of  the  spine  and  marked  tenderness 
over  the  spinous  processes  of  the  vertebrae  and  adjacent  skin  are  the 
prominent  symptoms  of  this  affection. 

The  j:»ain  is  of  a  most  distressing  kind,  usually  described  by  patients 
as  a  severe  "  ache."  It  is  very  commonlv  experienced  between  the 
shoulder-blades  and  in  the  lumliar  region ;  but  it  may  extend  into  the 
thighs  and  down  the  area  of  distribution  of  the  sciatic  nerves. 

Nausea  and  vomiting  may  coexist  with  tenderness  confined  to  the 
cervical  spines. 

The  h)/pe)'sesthesia  is  often  of  an  extreme  kind.  It  exists  over  the 
vertebral  spines.  The  slightest  pressure  along  the  spine  may  call  forth 
evidences  of  acute  suffering  on  the  part  of  the  patient. 

The  general  health  is  usually  below  par.  The  urine  may  be  loaded 
with  phosphates,  the  digestive  functions  poor,  the  eyes  asthenopic,  and 
the  mental  condition  sluggish  and  apathetic. 

No  evidences  of  impairment  of  motility  are  observed,  nor  is  there 
any  anfesthesia.     The  bladder  or  rectum  is  never  paralyzed. 

Treatment. — The  reader  is  referred  to  my  remarks  on  the  treatment 
of  spinal  neurasthenia  and  hysteria. 

FUNCTIONAL   PARAPLEGIA. 

The  lower  limbs  may  sometimes  be  paralyzed  without  an  organic 
cause.     We  encounter  this  condition  chiefl}'  in  women  and  children. 

Etiology. — Among  the  causes  of  this  condition  may  be  mentioned 
hysteria,  aui^mia,  blood  poisons  (malaria,  lead,  arsenic,  phosphorus, 
ergot,  alcohol,  etc.),  ovarian  irritation,  phimosis,  and  many  other  forms 
of  reflex  irritation.  I  believe  that  "  eye-strain  "  is  a  factor  in  these  cases 
too  commonly  overlooked. 

Symptoms. — When  hysteria  exists,  Drummond  thinks  that  an  in- 
scnsi])ility  to  pain,  but  not  to  touch  or  temperature,  is  peculiarly  char- 
acteristic.    Duchenne,  on  the  other  hand,  regards  the  loss  of  muscular 


436  LECTURES   ON   NERVOUS   DISEASES. 

sensibility   as    of   great   diagnostic    inij)ortance.      Todd    has   described 
certain  facial  changes  (p.  170j  as  of  value  in  recognizing  tliis  condition. 

Reynolds  has  described  a  type  of  functional  paraplegia  "  dependent 
piireli/  upon  idea^^''  in  wliich  the  patient  is  strongly  impressed  with  tiie" 
fact  that  voluntary  movement  is  impossible.  He  claims  that  this  state 
is  not  necessarih'  hysterical. 

In  malarial  jMrajyleyia,  the  paralysis  is  said  to  be  intermittent  in 
type.     I  have  never  observed  a  case  of  this  kind. 

In  7'ejlex  paraplegia^  the  bladder,  external  genitals,  urethra,  ovaries, 
and  the  eye  may  act  as  the  exciting  cause. 

In  alcoholic  paraplegia^  the  symi)toms  of  "  multiple  neuritis  "  are 
apt  to  be  encountered  ;  hence  this  condition  is  not  purely  functional  in 
many  cases.  Pains  in  the  limbs  and  the  coexistence  of  the  "  reaction  of 
degeneration  "  (p.  189)  are  diagnostic  of  the  latter  condition. 

Treatment. — The  removal  of  the  cause  and  steps  judiciously  directed 
toward  the  improvement  of  the  general  health  are  indicated.  Electricity, 
massage,  tonics,  etc.,  are  beneficial.  In  my  opinion,  a  correction  of 
"  eye-strain  "  will  generally  prove  of  immediate  service  to  a  large  pro- 
portion of  adult  cases. 

WRITERS'   CRAMP. 
(Prof essional  Cramp  ;  Mogigrajihia ;   Grajyhospasm ;   Cheirospasm.) 

Writers,  pianists,  violinists,  telegraphers,  the  counters  of  paper 
bills,  etc.,  often  become  unable  to  pursue  their  vocations  from  a  peculiar 
form  of  weakness  and  pain,  or  a  tendency  toward  sudden  spasm  of  the 
muscles  of  the  hand  and  forearm. 

Etiology. — An}^  occupation  which  requires  incessant  use  of  a  certain 
set  of  muscles  of  the  forearm  or  hand  maj-  lead  to  this  distressing  con- 
dition. It  is  doubtful  to  my  mind  if  injuries,  sprains,  or  exposure  to 
cold  ever  induced  this  morbid  state.  I  regard  causes  of  that  character 
as  mere  coincidences. 

Symptoms. — This  condition  develops  gradually.  The  patient  feels 
at  first  a  peculiar  sense  of  distress  or  fatigue  in  performing  for  any 
length  of  time  the  vocation  which  has  induced  it.  This  sense  of  distress 
may  be  in  the  fingers  or  forearm.  It  is  accompanied  sooner  or  later  bj- 
a  peculiar  awkwardness  in  the  finger-movements,  a  sense  of  stiffness  in 
the  fingers,  or  a  tendency  to  uncontrollable  spasm  of  the  fingers  when 
these  acts  are  persisted  in. 

Gradually  these  symptoms  increase  in  severity.  The  fingers  become 
more  and  more  uncontrollable  when  used  by  the  patient  in  his  vocation. 
For  example,  when  writing,  the  pen  may  be  flung  from  the  hand  or 
pressed  A'iolently  upon  the  page.  A  pain  becomes  marked  along  the 
arm,  often  as  high  as  the  shoulder.     After  ceasing  all  attempts  at  writing, 


TETANY.  437 

the  liml)  affected  may  feel  relieved  by  rubbing  it  and  kneading  the 
muscles  for  some  time.  In  many  cases,  the  vocation  which  has  occa- 
sioned the  cramp  has  to  be  abandoned. 

Strange  as  it  may  seem,  these  patients  can  use  their  affected  hand 
for  any  other  purpose  with  their  accustomed  facility.  I  have  seen  cases 
where  the  patient  could  draw  for  hours  but  could  not  write  for  one 
minute  without  distress.  Some  sufferers  learn  to  use  the  left  hand,  so 
as  to  avoid  using  the  afflicted  member.  If  the  left  hand  is  then  over- 
taxed, the  condition  tends  to  become  bilateral. 

This  disease  is  ver3'  persistent,  after  it  is  well-developed.  I  per- 
sonal!}^ suffered  from  it  for  manyj^ears;  and  am  still  unable  to  write 
continuously  with  a  pen  for  any  length  of  time  without  severe  distress. 
I  can  use  a  type-writer,  however,  for  hours  without  the  slightest  symptom 
of  cramp. 

Respecting  the  morbid  anatomy  of  this  disease,  many  theories  have 
been  advanced.  Althaus  regards  it  as  an  exhaustion  and  abnormal 
irritability  of  the  coordinating  centres  in  the  upper  part  of  the  cord. 
Some  authors  consider  it  an  affection  of  the  muscular  system  only  or  of 
the  terminal  plates  of  the  nerves.  Ross  claims  that  he  can  locate  the 
disease  by  the  electrical  reactions  of  the  affected  muscles.  He  places  it 
in  the  ganglionic  spinal  cells,  when  the  reactions  are  diminished ;  and  in 
the  cortex,  when  the  reactions  are  intensified. 

Treatment. — Entire  rest  from  the  occupation  that  causes  distress  is 
the  first  step  in  the  treatment.  This  must  be  ensured  for  many  months, 
if  possible. 

Some  patients  who  cannot  do  this  are  benefited  by  wearing  a  rubber 
band  around  the  forearm ;  others  by  holding  the  pen  in  an  imusual  way ; 
a  few,  by  employing  a  cork  pen-holder  of  an  extreme  size  (often  over  an 
inch  in  diameter) ;  while  many  have  recourse  to  a  type-writer  for  corre- 
spondence. 

Showering  the  arm  in  hot  and  cold  water  alternatel}- ,  and  using 
friction,  percussion  of  tlie  affected  muscles,  and  massage  (WoW's 
method)  after  the  water  application  is  often  very  beneficial. 

Blisters  and  the  actual  cautery  over  the  median  nerve  is  of  service 
in  many  cases.     It  must  be  kept  up  for  some  weeks 

Static  sparks  to  the  cervical  spinal  segments  and  to  the  affected 
forearm  and  hand  often  give  immediate  relief 

TETANY. 

This  condition  is  characterized  by  paroxysms  of  tonic  muscular 
spasm  confined  to  groups  of  muscles.  It  is  also  known  as  "  intermittent 
tetanus  "  and  "  inter-mitten t  cramj).'''' 

The   upper   extremities   are   most   often   attacked.     Generally   the 


438  LECTURES   ON   NERVOUS   DISEASES. 

spasnis  are  bilateral  in  character.  In  exceptional  cases  they  ma}'  be 
unilateral.  Sometimes  the  spasms  are  confined  to  the  legs,  and  occa- 
sionall}'  the  muscles  of  the  back,  tiiorax,  and  abdomen  ma}'  be  involved. 
Cases  where  the  attacks  have  been  general  in  character,  affecting  the 
limits,  trunk,  and  even  the  face,  have  been  reported. 

Etiology, — This  disease  is  most  frequentl}'  encountered  in  children 
at  the  time  of  dentition,  and  at  the  age  of  pubert}'.  It  is  rare  in 
advanced  life. 

Heredity  seems  to  be  apparent  in  some  cases.  Several  of  one 
family  have  been  so  afflicted,  according  to  Mni'doch,  and  the  researches 
of  Bouchut  seem  to  show  a  histor}-  of  neurotic  affections  in  the  ancestral 
line  of  many  so  afflicted. 

A  state  of  loiv  vitality  is  generalh'  present  in  these  subjects.  Rickets, 
acute  infectious  diseases,  impaired  digestive  functions,  etc.,  are  among 
the  predisposing  causes. 

Among  the  exciting  causes  may  be  mentioned  a  marked  exposure  to 
cold  or  dampness,  rheumatism,  peripheral  irritation  of  all  kinds,  and 
violent  mental  excitement. 

Morbid  Anatomy. — Little  is  positively  known  respecting  the  morbid 
changes  which  probablj'  exist  in  the  nerves  or  the  nerve-centres,  Weiss 
believes  that  diseases  of  the  sj^mpathetic  system  exists  and  induces 
circulator}'  changes  in  the  spinal  cord. 

Symptoms. — These  ma}'  be  grouped  into  two  classes,  the  prodromal 
and  the  actual. 

The  prodromal  symptoms  may  include  pains  in  the  limbs,  formica- 
tion, coldness  of  the  extremities,  vertigo,  a  sense  of  confusion  in  the 
head,  and  tinnitus  aurium.  They  may  exist  for  days  or  weeks  prior  to 
the  attack. 

The  symptoms  of  an  attack  may  occur  after  mental  excitement  or 
excessive  muscular  effort.     They  may  occur  at  night  or  during  the  da3^ 

When  the  upper  limbs  are  attacked,  the  flexors  of  the  fingers 
(usually  of  each  hand)  and  also  the  flexors  of  the  wrist  cause  the 
attitude  of  the  hand  to  assume  a  position  which  Trousseau  very  aptly 
compares  to  that  of  an  obstetrician  when  about  to  pass  the  hand  into 
the  vagina.  Occasionally  the  forearms  are  flexed,  and  the  arms  are 
drawn  to  the  chest  to  an.  extent  sufficient  to  cause  a  crossing  of  the 
distorted  hands  over  the  epigastrium.  In  very  exceptional  instances 
the  spasm  is  unilateral  and  the  extensors  may  be  attacked.  During  the 
paroxysm  the  muscles  are  very  prominent  and  firm,  and  are  sensitive  to 
pressure. 

When  the  lotcer  limbs  are  attacked  the  foot  is  distorted  at  the  ankle  by 
spasm  of  the  calf-muscles,  the  leg  is  extended  upon  the  thigh,  the  big  toe 
is  drawn  beneath  the  adjacent  toe,  and  the  thighs  are  strongly  adducted. 


TETANY.  439 

When  the  trunk  is  attacked  the  back  muscles  may  cause  opis- 
thotonos or  ])leurosthotonos.  Again,  the  spine  may  be  bent  anteriorly. 
The  chest-muscles  ma}'  cause  disturbances  of  respiration  of  an  alarming 
kind.  The  muscles  of  the  neck  may  create  c^'anosis,  prominence  of  the 
jr.gulars,  and  protrusion  of  the  ej^eballs. 

During  the  paroxy><ni  the  contractures  maj-  be  partially  overcome 
bj^  a  voluntary  effort,  but  the  deformity  returns  at  once  Avhen  the  effort 
is  suspended.  The  contractures  may  even  persist  during  sleep.  Fibrillary 
contractions  are  often  observed  during  the  paroxysm. 

The  duration  of  the  attacks  varies  from  a  minute  to  several  da3's. 
They  may  return  with  great  frequency  or  at  long  intervals. 

The  attacks  are  not  excessively  painful,  as  a  rule.  They  are 
generally  accompanied  by  a  sense  of  tingling,  formication,  coldness,  or 
slight  neuralgic  pains  of  a  shooting  character.  Fever  and  sweating  may 
be  observed  in  some  cases. 

Trousseau  lajs  much  stress  upon  the  diagnostic  importance  of  a 
test  to  be  employed  during  the  intervals  between  the  paroxysms,  which 
consists  in  the  ability  to  induce  these  attacks  at  will  by  pressing  upon  the 
arteries  or  verve-trunks  of  the  arm.  After  such  pressure  of  two  or  more 
minutes  the  spasm  occurs.  It  rapidly  disappears  when  the  pressure  is 
removed.  The  same  test  can  be  applied  to  the  crural  artery  and  the 
sciatic  nerve,  but  with  more  imcertainty. 

The  electrical  irritability  of  the  affected  motor  nerves  is  markedl}^ 
increased.  The  nerve  responds  to  abnormalh^  weak  fai'adaic  currents. 
Applications  of  galvanic  currents  to  the  nerve-trunk  by  the  polar 
method  show  the  following  conditions  :  C.C.C.  and  A.O.C.  occur  ver}' 
early ;  cathodal-closure-tetanus  and  anodal-closure-tetahus  are  rapidly 
developed  ;  finally,  anodal-opening-tetanus  is  produced  in  almost  every 
case  with  ease,  and  cathodal-opening-tetanus  in  some  cases. 

Diagnosis. — This  disease  may  be  confounded  with  tetanus,  hys- 
terical contractures,  and  ergotism. 

In  tetanus,  there  is  an  inability  to  use  the  muscles  of  mastication, 
more  pain,  a  traumatic  history,  and  a  general  rigidity  and  abnormal 
posture  of  the  limbs  and  trunk. 

In  hysterical  contractures,  the  test  of  Trousseau  is  inoperative,  there 
is  no  increase  of  the  mechanical  and  electrical  irritabilit}'  of  motor 
nerves,  children  and  males  are  seldom  attacked,  and  the  history  of  the 
case  is  suggestive  of  hysteria. 

In  ergot  poisoning,  the  history  of  the  case  would  point  clearly  to  the 
exciting  cause  of  the  attacks. 

Prognosis. — These  sufferers  usually  recover  perfectly  after  a  lapse  of 
time.  The  disappearance  of  Trousseau's  phenomena,  and  the  abnormal 
irritability  of  the  motor  nerves,  is  indicative  of  a  favorable  change  in 


440  LECTURES   ON  NERVOUS    DISEASES. 

the   patient.      Recurring   paroxysms   are   to   be   anticipated    for   some 
montiis  after  the  first  attack. 

Treatment. — If  a  history  of  rheumatism  or  a  rheumatic  tendency 
can  be  elicited,  it  is  well  to  give  iodide  of  potassium,  salicylic  acid,  or 
the  oil  of  wintergreen.  Ice-bags,  wet-cupping,  and  blisters  to  the  spine  ; 
the  application  of  the  actual  cautery,  and  galvanism  to  the  spine  have 
been  recommended  by  different  authors. 

The  general  health  of  the  patient  should  be  restored  by  all  judicious 
means.  Tonics,  massage,  good  hygiene,  nutritious  food,  stimulants  in 
moderation,  and  moderate  exercise  will  conduce  toward  that  end. 

Among  the  electrical  applications,  static  sparks  to  the  limbs  and 
spine,  general  faradization,  the  polar  action  of  the  anode  to  tender 
points  applied  by  the  stabile  method,  and  labile  applications  of  the 
anode  to  the  peripheral  nerves  (stroked  slowly  from  the  distal  extremity 
of  the  nerve  toward  the  proximal  end)  have  proven  of  service  in  many 
cases. 

THOMSEN'S   DISEASE. 
(Myotonia   Congenita — Congenital  Muscular  Spasm. ^ 

In  this  disease,  a  tendency  of  the  muscles  to  tonic  spasm  during 
attempts  at  voluntary  movement  is  the  characteristic  feature. 

By  such  spasms,  the  execution  of  intended  movements  of  the  limbs 
is  always  more  or  less  delayed,  and  sometimes  entirely  prevented. 

This  disease  is  also  known  as  "  Myotonia  Congenita,"  because  it  is 
seldom,  if  ever,  observed  except  in  patients  who  are  not  predisposed  to 
it  by  heredity.  Dr.  Thomsen,  who  first  described  this  aflfeetion,  noted 
its  occurrence  in  five  generations  of  his  own  family.  He  suffered  from 
it  himself,  as  did  also  one  of  his  sons.  A  very  complete  monograph  on 
this  subject  has  been  published  by  Erb,  who  has  collected  and  analyzed 
all  cases  reported  to  that  date.  Jacoby  and  Dana  have  lately  added  to 
the  literature  of  this  affection. 

Etiology. — As  has  already  been  stated,  heredity  plays  a  very  im- 
portant part  in  this  disease.  In  one  reported  case,  fright  seems  to  have 
acted  as  an  exciting  cause.  It  is  questionable,  howcA^er,  if  this  disease 
ever  occurs  without  some  congenital  defect  either  in  the  spinal  cord  or 
in  the  muscles  themselves.  A  late  monograph  upon  this  subject  by 
Dr.  G.  W.  Jacoby  seems  to  show  conclusiveh'  that  muscular  anomalies 
w^ere  present  in  the  case  reported  by  him. 

Morbid  Anatomy. — Although  this  disease  has  been  classed  by  me  as 
a  functional  disease  of  the  spinal  cord  (because  no  spinal  changes  have 
ever  been  shown  to  exist  in  connection  with  it),  it  must  be  said  that  the 
muscles  appear  to  show  characteristic  conditions  which  are  probably 
congenital.     The   individual  muscular  fibres  are  greatly  augmented   in 


thomsen's  disease.  441 

point  of  size,  and  the  number  of  their  nuclei  is  in  excess  of  that  observed 
in  healthy  muscle. 

The  muscles  are  generally  unnaturally  large  in  this  disease.  This 
gives  to  the  patient  an  appearance  of  strength,  which  is  in  marked 
contrast  to  the  actual  power  of  contraction  which  the  patient  possesses. 
The  anomalies  of  muscular  construction  which  have  been  referred  to 
necessarily  add  to  the  size  of  each  individual  muscle.  But,  on  the  other 
hand,  such  a  muscle  appears  to  be  more  liable  to  become  tetanic  when 
called  into  pla}-  by  the  act  of  will. 

Symptoms. — Typical  cases  of  this  disease  exhibit  in  very  early 
youth,  to  a  moderate  degree,  the  disorder  of  movements,  which  becomes 
more  pronounced  later  in  life.  A  histor}'  of  a  similar  affection  can  be 
found  upon  inquiry  to  have  existed  in  some  of  the  patient's  ancestry. 
After  a  period  of  rest  the  patient  experiences  a  peculiar  tension  and 
stiffness  of  the  muscles  when  any  voluntary  movement  of  the  limbs  is 
attempted.  This  stiffness  may  be  so  marked  in  some  cases  as  to  com- 
pletely arrest  the  intended  movement  for  a  time.  It  graduall}^  dis- 
appears, however,  and,  by  the  aid  of  continued  movements,  the  patient 
after  a  time  regains  complete  control  over  his  muscles. 

In  addition  to  this  peculiar  muscular  state,  the  patient  is  also 
rendered  unable  to  voluntarily  relax  the  muscles  quickly. 

The  muscles  of  the  lower  limbs  are  more  frequentl}'  affected  than 
those  of  the  upper.  In  some  cases,  the  muscles  of  the  tongue,  face,  e3-es, 
and  also  those  of  mastication,  are  aff'ected.  Involvement  of  the  tongue 
by  spasms  of  this  character  gives  rise  to  a  peculiar  hesitancy  in  speech. 
Awkwardness  in  the  mastication  of  food  is  observed  wiienever  the 
muscles  which  move  the  lower  jaw  are  attacked. 

When  the  muscles  of  the  lower  limbs  are  affected  with  this  disease 
the  patient  is  very  apt  to  experience  great  difficulty  in  attempting  to 
rise  and  walk,  after  a  prolonged  recumbent  or  sitting  posture.  Such  sub- 
jects have  been  known  to  fall  as  soon  as  eff"orts  to  walk  were  attempted. 
Fibrillary  contractions  of  the  muscles  may  occasionally  be  detected. 
Continued  movement  and  the  application  of  heat  tend  to  diminish  the 
spasm,  while  mental  excitement  and  cold  usually  aggravate  it. 

Again,  the  muscles  in  these  patients  show  an  abnormal  excitability 
to  mechanical  and  electrical  stimuli.  Artificially  produced  contractions 
are  apt  to  be  very  much  prolonged.  Erb  describes  peculiar  "wave-like 
contractions "  in  the  muscles  of  the  limbs,  whenever  galvanic  currents 
of  sufficient  intensity  are  employed  upon  the  patient  by  the  stabile  polar 
method.  These  contractions,  according  to  this  author,  alwaj's  tend  to 
pass  toward  the  anode.  After  a  time  they  subside  "  like  waves  of  water 
produced  bj-  a  falling  stone."  Any  increase  of  the  strength  of  the 
current,  however,  tends,  as  a  rule,  to  reproduce  them. 


442  LECTUKES   ON  NERVOUS  DISEASES. 

To  test  this  reaction  in  the  upper  extremities,  one  pole  maj'  be 
phaced  at  the  najjc  of  the  neck  and  the  other  in  the  pahn  of  the  hand  or 
at  the  annuhir  ligament  of  the  wrist-joint  on  its  palmar  aspect.  To  test 
it  in  the  lower  extremity,  one  pole  should  be  at  the  neck  and  the  other 
ma3'  be  placed  adjacent  to  the  patella  or  upon  the  tendo-Achilles.  The 
strength  of  the  current  employed  varies  from  six  to  twenty  milliaraperes. 
Jacoby  has  observed  an  absence  of  any  fixed  relationship  of  Ca.C.C. 
and  An.C.C.  to  each  other,  as  exists  in  healthy  muscle  (page  190). 

The  duration  of  this  disease  is  limited  by  the  life  of  the  patient; 
although  remission  and  exacerbations  have  been  described  by  ditterent 
obserA'ers. 

Diagnosis.— This  disease  is  to  be  distinguished  from  muscular 
hypertrophy  by  the  presence  of  the  spasms,  and  the  peculiar  electrical 
phenomena  already  described.  The  reflexes  give  evidence,  also,  of  an 
unusually  prolonged  muscular  response. 

Treatment.— Gymnastic  exercises,  warm  baths, and  judicious  electri- 
cal treatment  ma}'  possibly  afford  some  relief. 

ACUTE  ASCENDING  SPINAL  PAEALYSIS. 
(Kussmaul-Landry^s  Paralysis.) 

This  disease,  as  far  as  we  at  present  know,  is  not  associated  with 
anatomical  changes  in  the  nervous  system.  It  consists  of  a  tendency 
toward  progressive  paralysis,  which  slowdy  creeps  from  below  upward 
in  a  more  or  less  irregular  wa}'.  There  is  an  absence  of  atrophy ;  and 
no  sensory  or  trophic  disturbances  are  observed.  There  is  no  paralysis 
of  the  bladder  or  rectum.  The  irritability  of  the  parah'zed  muscles  is 
retained. 

Etiology. — This  disease  is  a  rare  one.  It  is  more  common  among 
males  than  females ;  and,  as  a  rule,  it  aflTects  middle  life. 

Its  exciting  causes  are  ver}'  obscure.  It  has  been  observed  to  follow 
mental  excitement,  exposure  to  cold,  suppressed  menstruation,  acute 
infectious  diseases,  coitus  in  the  standing  posture.  The  syphilitic  history 
ma}'  be  detected  in  a  certain  proportion  of  persons  so  afflicted. 

Morbid  Anatomy.  —  Little  if  an^'thing  is  known  respecting  the 
changes  which  occasion  this  disease.  Westphal  concludes  from  his 
investigations  that  it  is  the  result  of  some  unknown  infection;  because 
he  detected  changes  in  the  intestinal  follicles  and  the  mesenteric  glands 
in  a  number  of  cases. 

Symptoms. — The  paralysis  may  develop  suddenly ;  or  it  may  be 
preceded  hy  slight  fever,  pain  in  the  back  and  limbs,  tingling  and  other 
forms  of  abnormal  sensation.  The  paralytic  symptoms  do  not  always 
follow  a  strictl}'  ascending  course.  They  maj'  begin  in  one  or  both  feet 
and  then  skip  to  the  upper   extremities,  the  neck,  chest,  or  abdomen. 


ACUTE   ASCENDING    SPINAL   PARALYSIS.  443 

This,  however,  is  not  always  the  case.  In  rare  instances,  tlie  impairment 
of  motion  has  apparently  pursued  a  descending  course;  and,  in  one  case 
reported  by  Westplial,  the  nuclei  of  the  medulla  were  alone  implicated 
and  ''bulbar"  symptoms  appeared  at  the  onset. 

In  most  cases,  a  paresis  first  appears  ;  this  subsequently  deepens 
into  complete  paralysis.  A  sense  of  fatigue  in  the  limbs  is  first  noticed 
by  the  patient,  and  walking  soon  becomes  extremely  difficult.  For  this 
reason  these  patients  usually  take  to  bed  earlj-. 

When  the  back  muscles  become  paralyzed,  it  is  impossible  for  the 
patient  even  to  sit  up.  Paralysis  of  the  muscles  of  the  abdomen  renders 
coughing,  sneezing,  expiration,  defecation  and  micturition  difficult. 
When  the  intercostal  muscles  are  paralyzed,  inspiration  is  seriously 
disturbed,  and  the  most  marked  difficulty  in  breathing  may  occur  when- 
ever the  phrenic  nerve  becomes  affected.  Sooner  or  later  the  movements 
of  the  upper  extremities  are  rendered  difficult  or  are  totall3^  lost. 
Whenever  the  medulla  is  implicated,  speech  becomes  very  much  impaired, 
and  the  act  of  swallowing  ma^-  be  attended  with  great  difficulty.  It  is 
very  rare  to  observe  any  paralysis  in  the  nerves  of  cerebral  origin. 

No  atrophy  is  detected  in  the  paralyzed  muscles,  and  the}-  retain 
their  normal  irritability  to  electrical  stimulation. 

In  very  exceptional  instances  only  do  the  sensory  functions  give 
any  evidence  of  serious  impairment.  Cases  have  been  reported,  however, 
where  the  sensations  of  pain  and  temperature  have  been  imperfectly 
conducted,  and  where  the  muscular  sense  has  been  somewhat  diminished 
Anesthesia  and  hyperiesthesia  have  also  been  observed.  Tliere  seems 
to  be  a  tendency  to  diminution  or  abolition  of  the  skin  and  tendon 
reflexes  late  in  the  disease. 

In  some  cases  a  marked  enlargement  of  the  spleen  and  clinical 
evidences  of  albuminuria  have  been  detected. 

Diagnosis. — This  disease  may  be  confounded  with  an  ascending 
myelitis,  poliomyelitis  anterior  acuta,  and  acute  multiple  neuritis. 

From  myelitis  of  the  ascending  type,  it  may  be  recognized  by  the 
absence  of  fever  and  sensor}^  disturbances,  by  the  fact  that  bed-sores 
do  not  occur,  and  by  the  non-occurrence  of  vesical  and  rectal  com- 
plications. 

From  poliomyelitis^  it  may  be  told  hy  its  progressive  character,  and 
the  absence  of  rapid  atrophy  in  the  paralyzed  muscles.  The  "  reaction 
of  degeneration  "  is  present  in  poliomyelitis  ;  while  it  is  generally  absent 
in  ascending  paralysis. 

From  acute  multiple  neuritis^  it  differs  in  that  marked  pain  and 
sensory  disturbances  are  usually  absent,  and  in  the  fact  that  the  affected 
nerves  and  muscles  do  not  rapidly  lose  their  irritability  to  electrical 
currents. 


444  LECTURES   ON   NERVOUS   DISEASES. 

Prognosis. — This  disease  usiuiU}'  runs  an  acute  and  progressive 
course  ;  hence  tlie  prognosis  is  naturally  grave,  although  recovery  has 
been  observed.  The  development  of  "bulliar"  symptoms  generally 
indicates  the  approach  of  a  fatal  termination.  The  more  rapid  the 
development  of  paralysis  of  a  complete  kind,  the  more  serious  is  the  out- 
look for  the  patient.  The  duration  of  the  disease  is  generally  a  short 
one.     It  may  prove  fatal  in  from  four  days  to  as  many  weeks. 

Treatment. — If  the  disease  can  be  shown  to  be  connected  with  any 
of  the  clinical  manifestations  of  syphilitic  infection,  the  remedies  sug- 
gested on  page  291  should  be  administered.  It  is  well  to  make  use  of 
the  actual  cautery,  dry  cups,  or  ice-bags  to  the  spine.  The  internal 
remedies  suggested  b}^  authors  comprise  the  iodide  of  potash,  full  doses 
of  ergot,  belladonna,  and  strychnia.  The  galvanic  current  may  be  applied 
to  the  spine,  preference  being  given  to  the  polar  action  of  the  cathode. 

ABNORMAL    VASCULAR    CONDITIONS    OF   THE    SPINAL   CORD   AND   ITS 

COVERINGS. 

Under  this  head  I  have  included,  "in  a  previous  table,  spinal  con- 
gestion, spinal  antemia,  spinal  embolism,  atheroma  of  the  spinal  vessels, 
fatty  degeneratian  of  the  vascular  coats,  and  aneurismal  dilatations. 

Of  these,  only  the  first  two  can  be  described  as  conditions  which  are 
clinically  recognized.  The  other  four  are  pathological  states  which  tend 
when  present  to  induce  structural  changes  within  the  substance  of  the 
spinal  cord.  Thej^  are  more  directly  concerned,  therefore,  with  the 
etiology  of  organic  spinal  diseases  than  with  their  SA'mptomatology. 
One  form  of  si^inal  anaemia  has  been  already  considered  under  the  head 
of"  spinal  irritation." 

SPINAL   CONGESTION   OR  HYPEREMIA. 

The  distinction  between  congestion  and  hvpememia  is  one  of  degree 
rather  than  of  kind.  In  both  conditions  we  encounter  dilatation  of  the 
vessels  with  an  excess  of  blood.  In  h^-peraemia,  the  current  is  unusualh' 
rapid;  in  congestion,  it  is  unnaturally  slow. 

Clinicalh',  the  line  of  distinction  between  hypersemia  and  inflamma- 
tion is  very  difficult,  if  not  impossible,  to  draw.  One  may  be  simply 
a  precursor  of  the  othei'.  As  the  vessels  of  the  pia  are  the  chief 
sources  of  supply  to  the  spinal  cord,  hvperaemia  of  the  cord  and  me- 
ninges usually  go  hand  in  hand.  Its  symptoms  must,  therefore,  be  of 
necessity  closely  allied  to  those  of  spinal  meningitis  and  myelitis. 
When  the  pia  is  diseased,  the  spinal  cord  is  almost  invariably  afi'ected 
simultaneously  to  a  greater  or  less  degree. 

Etiology. — A  sudden  checking  of  the  perspiration  by  draught  of  cold 
air,  bathing,  etc.,  is  generally  regarded  as  tending  to  excite  this  condition. 


SPINAL   CONGESTION    OE   HYPEK^MIA.  445 

Excessive  fatigue,  violent  excitement,  unnatural  indulgencies  in 
veneiy,  suppression  of  the  menstrual  discharges,  the  etfects  of  com- 
pressed air,  prolonged  physical  or  mental  exertion,  blows  and  falls,  etc., 
have  also  been  mentioned  by  some  authors  as  apparent  causes  of  spinal 
hyperaemia. 

Personally,  I  am  inclined  to  believe  that  most  of  the  symptoms 
usually  attributed  by  authors  to  tins  morbid  state  are  dependent  upon  a 
neuropathic  tendency  whose  exciting  causes  will  be  discussed  in  full  in 
the  section  which  relates  to  functional  nervous  diseases. 

Symptoms. — These  are  to  be  attributed  in  a  general  way  either  to 
irritation  or  a  state  of  depression  of  the  spinal  functions.  They  ma}', 
therefore,  vary  with  each  case,  and  closely  simulate  the  first  symptoms 
observed  in  spinal  meningitis,  spinal  tumors,  and  myelitis. 

Hammond,  Browne-Sequard,  Radcliffe,  Ollivier,  and  others,  who 
have  written  upon  this  condition,  describe  among  the  symptoms  man}'' 
clinical  features  which,  in  my  opinion,  are  not  always  distinguishable 
from  those  occasioned  by  the  organic  diseases  mentioned.  Thus,  for 
example,  pain,  disturbances  of  motility  and  sensation,  the  cincture- 
feeling,  a  lowering  of  the  temperature  in  parts  below  the  lesion,  inter- 
ference with  breathing  and  the  action  of  the  heart,  a  loss  of  control  of 
the  bladder  and  rectum,  a  diminution  of  the  electro-muscular  con- 
tractility, the  development  of  bed-sores,  etc.,  are  what  we  are  apt  to 
observe  whenever  the  spinal  cord  is  subjected  to  irritation  or  when  its 
functions  are  in  any  way  interfered  with.  The  clinical  history  of  each 
case,  combined  with  prolonged  observation  of  the  patient,  can  alone 
enable  us  to  exclude  organic  spinal  changes. 

Respecting  the  pain  of  spinal  congestion,  it  is  claimed  that  the 
recumbent  posture  increases  it ;  and  also  that  the  standing  posture  adds 
to  the  distress  when  the  congestion  is  localized  in  the  lower  spinal 
segments.  This  is  attributed  to  the  etfects  of  gravity.  It  is  also  stated 
that  a  sudden  blow  or  shock,  as  a  false  step,  for  example,  adds  to  the 
pain  in  the  spine. 

Aneesthesia,  or  a  sense  of  tingling  and  foi'mication.,  ma}^  exist  in  the 
feet  (chiefly  in  the  plantar  surface  of  the  toes)  whenever  the  dorsal  or 
lumbar  segments  are  locally  congested. 

Paresis  of  the  legs,  or  actual  p)^raplegia,  may  be  developed.  The 
patient  can  usually  move  the  limbs  when  sitting  or  in  bed,  although 
they  may  be  incapable  of  supporting  the  body. 

According  to  Hammond,  the  symptoms  of  spinal  congestion  are 
always  more  marked  on  rising  than  as  the  da}'  advances. 

Diagnosis.— This  condition  may  be  confounded  with  spinal  anaemia, 
myelitis,  spinal  meningitis  and  spinal  tumors. 

In  spinal  anaemia^  the  bladder,  when  attected,  is  impaired  before  the 


446  LECTURES   ON   NERVOUS   DISEASES. 

development  of  motor  weakness  in  the  legs,  while  the  reverse  order  is 
observed  in  spinal  congestion.  Ilyperaistliesia  is  developed  in  place 
of  anaesthesia  and  formication.  The  effects  of  a  recumbent  posture  tend 
to  cause  an  improvement  in  tiie  symptoms. 

In  mijelUis^  the  urine  is  apt  to  become  alkaline,  ii'respective  of 
decomposition  from  retention  within  the  bladder.  Moreover,  the 
paralysis  is  more  decided,  tlie  development  of  bed-sores  more  frequent, 
the  cincture  feeling  is  more  decidedly  marked,  and  the  pain  in  the  cord 
is  more  severe. 

In  spinal  meningitis^  the  tendenc}^  to  muscular  spasm,  the  pain  on 
movement  of  the  spine  and  of  the  paralyzed  limbs,  the  febrile  symptoms, 
the  muscular  twitchings,  and  the  tendency  toward  muscular  rigidity  are 
all  in  contrast  to  the  symptoms  of  simple  congestion. 

In  spinal  tumors,  the  loss  of  motility  is  most  marked  upon  one  side, 
and  sensory  disturbances  (antesthesia)  upon  the  other.  There  is  also  a 
history  of  tubercle,  cancer,  or  syphilis.  The  spinal  sjnnptoms  develop 
very  gradually,  as  a  rule. 

Prognosis. — There  is  a  tendencj-  in  all  cases  of  spinal  congestion  for 
the  disease  to  progress  along  the  cord.  Moreover,  the  development  of 
structural  disease  of  the  cord  is  liable  to  be  a  result  of  excessive  vascu- 
larity. The  prognosis  is  not  unfavorable,  if  the  case  be  one  of  a 
localized  t3'pe  and  unaccompanied  by  organic  or  inflammatory  disease  of 
the  cord  or  its  membranes. 

Treatment. — In  cases  of  an  acute  character,  where  the  symptoms 
develop  rapidly,  leeching  the  anus  will  indirectl}'  deplete  the  cord,  and 
dry-cups  over  the  spine  may  also  tend  to  relieve  the  congestion. 
Hammond  also  suggests  the  daily  use  of  three  drachms  of  the  sulphate 
of  magnesia  in  divided  doses  to  cause  watery  stools,  which  require  a 
determination  of  blood  to  the  intestinal  canal. 

Ergot  should  be  administered  in  large  doses.  I  have  given  it  in 
doses  of  a  drachm  of  the  fluid  extract  after  each  meal  for  many  weeks  at 
a  time  to  patients  without  any  S3'mptoms  of  ergot  poisoning.  Bella- 
donna, in  doses  of  fifteen  drops  of  the  tincture,  may  be  given  with 
benefit  three  times  a  day. 

The  emplo^-ment  of  the  hot  douche  to  the  spine — the  water  being 
poured  from  a  height  of  two  feet  upon  the  bare  back  for  five  minutes 
daily — is  highly  recommended  by  Hammond. 

Electricity  is  of  service  in  the  treatment  of  this  disease.  I  prefer 
the  withdrawal  of  static  sparks  from  the  spine  to  galvanism  or  faradism. 
I  have  also  employed  the  same  treatment  to  the  paralvzed  muscles  with 
good  results. 

Strychnia  and  phosphorus  are  strongly  contra-indicated,  according 
to  Hammond. 


SPINAL  ANEMIA.  447 


SPINAL    ANEMIA. 

One  form  of  this  condition  has  already  been  discussed  under  the 
head  of'  spinal  irritation."  This  disease  is  believed  by  some  observers 
to  depend  upon  an  antemia  of  the  posterior  columns  of  the  spinal  cord. 

Another  variety  is  thought  to  affect  the  antero-lateral  columns  of  the 
spinal  cord  (Fig.  91).  If  this  condition  be  recognized  as  a  distinct 
disease,  the  symptoms  will  be  of  necessitj^  connected  with  motilit}^ ;  and 
possibly  with  exaggerated  reflexes,  contracture,  and  atrophy.  It  will 
also  cover  all  of  the  so-called  "  functional  paralyses  "  whose  pathology  is 
now  unknown. 

I  cannot  express  my  full  concurrence  with  these  views  ;  ])ut,  with 
deference  to  those  advanced  by  others,  I  shall  here  giA'^e  the  main  features 
of  the  disease  as  generally  taught. 

Etiology. — Extreme  cold,  sleeping  on  damp  ground,  exhausting 
diseases,  spinal  embolism,  thrombosis  or  atheroma,  and  interference  with 
the  circulation  through  the  abdominal  aorta,  from  compression,  throm- 
bosis or  aneurism  of  that  vessel,  may  cause  spinal  anaemia.  Moreover, 
the  spinal  vessels  may  be  influenced  to  contract  through  the  agency  of 
the  vaso-motor  nerves,  as  an  indirect  result  of  peripheral  irritation  from 
any  cause,  such  as  the  ovaries,  intestine,  genitals,  eye-strain,  injuries  to 
nerves,  etc. 

Symptoms. — The  affected  segments  of  the  cord  give  evidence  of 
deficient  blood-supply  early  by  j^cLresis  of  certain  muscles.  It  is  claimed 
that  the  anterior  tibial  muscles  and  the  peronei  seldom  escape.  The 
paresis  rarely  prevents  walking,  although  the  gait  is  generally  feeble  and 
the  patient's  endurance  slight.     The  upper  limbs  are  seldom  paretic. 

The  sphmcter's  of  the  bladder  and  rectum  are  seldom  affected  ;  and 
the  paresis  of  the  limbs  is  not  usually  progressive  in  type. 

Sensory  disturbances  are  infrequent.  The  cincture  feeling  is  not 
developed. 

The  reflexes  may  be  normal  or  exaggerated  slightly.  They  are 
never  abolished. 

Prognosis. — If  the  exciting  cause  can  be  removed,  the  chances  for 
a  complete  recovery  are  good  ;  if  not,  the  spinal  cord  may  undergo 
softening. 

Diagnosis. — The  chief  points,  which  relate  to  the  discrimination 
between  this  disease  and  spinal  congestion,  have  already  been  given 
(page  445). 

Treatment. — The  utmost  care  should  be  exercised  in  ascertaining 
the  cause.  My  remarks  concerning  the  effect  of  "  eye-strain "  in  a 
preceding  section  should  be  carefully  considered,  and  all  necessary  tests 
should  be  made  early  to  determine  the  condition  of  this  organ  and  its 


448  LECTUEES   ON   NERVOUS    DISEASES. 

muscles.  In  the  liijht  of  lute  reseurches  made  in  this  direction,  I  am 
inclined  to  discredit  the  value  generally  placed  bj^  the  profession  upon 
many  of  the  other  reflex  causes  enumerated,  although  more  than  one 
cause  ma}'  exist  in  any  individual  case. 

The  general   treatment  should  be  directed  toward  improving  the 
vitality  of  the  patient. 


SECTION  V. 


FUNCTIONAL  NERVOUS  DISEASES. 


39  (449) 


SECTION  V. 

FUNCTIONAL  NEEVOUS  DISEASES. 

Under  this  heading  I  propose  to  discuss  certain  abnormal  conditions 
of  body,  in  consequence  of  which  some  special  form  of  disturbance  or 
derangement  of  the  nervous  functions  may  be  exliibited,  which  has  not, 
as  yet,  been  shown  to  depend  upon  any  positively  recognized  pathological 
state. 

Among  this  class  of  conditions  may,  in  my  opinion,  be  iucluded  a 
certain  percentage  of  epilepsy^  chorea^  hysteria^  and  h yatero-epilepsy .  In 
this  i^ercentage,  the  existence  of  organic  lesions  can  be  excluded.  Again, 
neurasthenia  (with  its  endless  variety  of  manifestations),  typical  attacks 
of  migraine  or  "  sick  headache,''^  certain  obstinate  types  of  neuralgia, 
and,  in  some  cases,  evidences  of  imperfect  j^erfoi-mance  of  some  of  the 
functions  of  the  abdominal  and  thoracic  viscera,  are  unquestionabl}^  to 
be  regarded  as  functional  neuroses. 

I  am  aware  that  I  am  at  variance  with  the  majority  of  authors  in 
thus  grouping  so  many  diseased  conditions  that  are  apparently  dis- 
cordant under  one  head.  I  may  be  severely  criticised  possibly  by  some 
for  so  doing.  I  may  even  be  taken  to  task  for  the  selection  of  the  term 
''  functional  nervous  disease,"  which  is  rejected  by  man3'  enthusiasts  in 
pathological  research. 

To  show,  however,  that  I  am  not  alone  in  the  position  taken,  I  take 
the  liberty  of  quoting  the  following  paragraphs  from  the  preface  of  a  late 
work*  upon  this  special  field  : — 

"  Pathological  anatomy  has  exercised  such  an  enormous  influence 
upon  the  advances  made  in  practical  medicine  within  the  last  twenty -five 
years,  that  many  pathologists  sneer  at  the  term  '  functional '  disease,  and 
deny  its  very  existence. 

"  While  we  fully  agree  that  there  can  be  no  morbid  manifestations 
without  a  change  in  the  material  structure  of  the  organs  involved,  we 
are  nevertheless  fully  convinced,  in  view  of  the  fruitless  search  of 
pathological  anatomists,  that  the  diseases  which  we  have  considered  in 
this  work  present  no  primary  anatomical  changes  which  are  visible  to 
the  naked  eye  or  the  microscope ;  in  other  words,  that  the  changes  are 
of  a  molecular  nature." 

Wliile  the  truth  of  this  statement  appears  to  me  self-evident,  I  haA^e, 
moreover,  other  reasons  than  those  urged  by  this  author  for  including 

*  Putzel — "  Functional  Nervous  Diseases,"  1880. 

(451) 


452  LECTURES   OX  NERVOUS  DISEASES. 

under  the  term  "  functional  "  nervous  diseases,  the  abnormal  states 
specified  by  me,  as  will  appear  later.  Tiiese  will  be  more  apparent  when 
I  call  attention  to  what  I  regard  as  of  vital  importance  in  some  of  these 
cases. 

THE    RELATIONSHIP    BETWEEN    FUNCTIONAL    NEUROSES    AND 
ANOMALIES   OF   THE   VISUAL   APPARATUS. 

The  study  of  defects  in  the  adjustment  of  the  eye-muscles  and  the 
relationship  which  exists  between  such  defects  and  nervous  diseases,  has 
not  been  generally  regarded  as  of  very  great  practical  importance  until 
of  late.  Many  of  our  best  text-books  upon  the  eye  do  not  deal  with  any 
such  muscular  defects,  except  in  relation  to  strabismus.  Some  give 
directions  for  testing  the  ocular  muscles,  that  are  in  direct  opposition  to 
the  views  which  are  here  advanced.  A  few  are  positively  misleading ; 
chiefly  on  account  of  errors  of  statement  concerning  points  where 
physiological  optics  come  into  play. 

I  may  be  pardoned,  tlieretbre,  if  I  review,  in  a  general  way,  a  few 
points  which  have  a  practical  bearing  upon  a  method  of  examination  and 
treatment  of  the  visual  apparatus,  which  is  to-day  exciting  considerable 
attention  among  scientific  medical  men,  especially  among  those  whose 
interest  centres  in  the  studj-  of  nervous  diseases  and  in  ophthalmology. 

What  I  have  to  say  here  includes  the  discussion  of  the  following 
points  of  inquiry  : — 

(1)  Wliat  steps  may  be  deemed  as  essential  to  success  in  the  diag- 
nosis and  treatment  of  certain  anomalies  of  the  visual  apparatus. 

(2)  Why  it  is  that  observations  in  this  direction,  when  too  hastily 
or  imperfectly  made,  are  peculiarh"  apt  to  be  untrustworthj'. 

The  limits  of  a  few  pages  will  hardly  suffice  for  me  to  cover  more 
than  a  few  of  the  more  important  points  comprised  under  these  headings. 
What  I  have  to  say  will,  therefore,  be  as  condensed  as  seems  to  me  per- 
missible. A  personal  experience,  derived  from  several  years  of 
continuous  research  in  this  field  upon  a  class  of  patients  afflicted 
exclusively  with  nervous  derangements,  and  from  more  than  five  hundred 
graduated  tenotomies  upon  the  recti  muscles  of  the  orbit,  justifies  me, 
I  think,  in  expressing  positive  convictions. 

The  views  which  I  shall  discuss  here  constitute  the  basis  of  a 
systematic  method  of  examination  for  and  treatment  of  certain  ocular 
defects,  whose  relationship  to  functional  nervous  diseases  seems  to  me 
to  be  now  established  beyond  dispute. 

Since  these  views  were  first  advanced  by  Dr.  George  T,  Stevens, 
they  have  attracted  no  small  amount  of  professional  attention.  In  spite 
of  the  fact  that  his  contributions  in  relation  to  this  subject  are 
remarkably  clear  and  succinct,  considerable  misapprehension  still  appears 


FUNCTIONAL   NEUEOSES   AND   VISUAL   APPARATUS.  453 

to  exist  in  tlie  minds  of  the  profession  at  large  relative  to  the  views 
advanced  by  him. 

I  ma}^  be  pardoned,  therefore,  if,  as  an  exj^onent  of  these  views,  I 
repeat  in  substance  much  that  has  already  appeared  in  print.  By  so 
doing,  I  hope  to  concentrate  attention  upon  certain  steps  employed  in 
the  examination  of  the  visual  apparatus,  whose  order  is  deemed  by  no 
means  unimportant,  and  in  some  of  which  the  observer  should  exercise 
no  small  amount  of  care. 

The  following  statements  are,  therefore,  deemed  by  me  as  worthy 
of  your  attention  : — 

(1)  The  view  is  held  that  e?'rors  of  i^efraction  (by  which  I  mean 
near-sightedness,  far-sightedness,  or  astigmatism)  often  modify  apparent 
muscular  anomalies  to  such  an  extent  as  to  render  the  early  detection  and 
correction  of  refractive  errors  imperative. 

This  point  is  of  vital  importance  in  the  treatment  of  many  patients. 
Clinical  observation  has  conclusive!}^  shown  that  one  of  the  most 
important  steps  in  correcting  what  is  commonly-  known  as  a  "  squint,"  or 
"  cross-eye,"  is  first  to  properly  detect  any  existing  error  in  refraction  and 
to  properly  correct  it.  Such  defects  should  always  be  sought  for  early, 
and  the  eftect  of  a  proper  glass  upon  the  deviation  of  the  axes  of  vision  from 
'.,heir  normal  position  which  demands  relief  should  first  be  carefully  noted. 
Many  cases  are  observed  by  oculists  where  spherical  glasses  alone  have 
corrected  a  marked  "  squint."  The  neglect  of  this  important  step  may 
prove  to  be  a  serioiis  omission,  as  it  may  lead  to  an  error  in  diagnosis 
or  treatment.  Let  me  impress  upon  you  the  fact  that  each  eye  of  every 
patient  must  be  separately  examined  for  refractive  errors,  and  rendered 
as  nearly  emmetropic  as  possible,  before  any  test  relating  to  the  ocular 
muscular  conditions  can  be  considered  as  reliable.  It  is  not  enough, 
therefore,  for  a  neurologist  to  provide  himself  simply  with  a  set  of  prisms 
with  which  to  examine  his  patients'  e3'es  for  suspected  muscular  errors. 
Au}^  tests  so  crudely  made  are  certainly  unscientific,  and  probably 
inaccurate. 

(2)  The  view  is  held  that  errors  of  refraction  can  only  he  positively 
determined  after  the  full  effects  of  atrojnne  ;  hence  the  step  of  dilating 
the  p)upil  is  deemed  of  importance  in  most  cases. 

There  are  two  sources  of  error  which  are  possible  in  all  oph- 
tlialmoscopic  examinations  as  a  step  toward  the  determination  of 
refraction. 

The  first  of  these  is  that  the  observer  may  not  be  able  to  perfectly 
relax  his  own  "  accommodation  "  while  using  the  instrument.  Most 
oculists  of  large  experience  believe  that  they  can  do  this  with  cer- 
tainty,— a  belief  which,  in  my  opinion,  is  perhaps  not  always  well 
founded.     The  second  source  of  error  lies  in  the  "  accommodation  "  of 


454  LECTURES   ON   NERVOUS   DISEASES.. 

the  patient.     This  cannot  always  be  relaxed  by  instructing  the  patient  to 
look  at  an  object  twenty  or  more  feet  distant  i'nnn  the  eye. 

I  am  satislied  that  mistakes  in  the  determination  of  refractive  errors 
by  the  ophthalmoscoi)e  are  far  more  frequent  than  are  generally  supposed. 

For  the  past  four  years  I  have  examined  the  eyes  of  every  patient 
intrusted  to  my  care  by  the  aid  of  test-type  both  before  and  after  the 
pupils  have  been  fully  dilated  by  atropine.  I  am  not  aware  that  I  have 
ever  lost  a  patient  by  the  use  of  this  drug.  In  my  experience,  intelligent 
persons  are  always  willing  to  submit  to  a  temporary  inconvenience  for 
the  purpose  of  obtaining  positive  information  respecting  any  point  that 
is  deemed  of  scientific  value  in  relation  to  themselves.  I  have  personally 
come  to  regard  the  ophthalmoscope  as  an  unreliable  instrument  for  the 
determination  of  refraction.  Its  use  is  rendered  compulsory,  however, 
in  very  young  children,  and  in  those  who,  from  ignorance  or  feeble- 
mindedness, are  unreliable  in  their  reading  of  test-t^pe. 

It  is  generally  accepted,  furthermore,  among  our  best  oculists  that 
astigmatism  (a  recognized  source  of  nervous  perplexity)  is  always  esti- 
mated more  accurately  with  the  pupil  widely  dilated  by  atropine  than 
with  the  normal  pupil. 

The  reasons  which  I  have  already  given  must  suffice  to  explain  why 
the  use  of  atropine  constitutes  a  most  important  preliminary  step  to  the 
detection  and  estimation  of  any  error  in  the  eye-muscles,  although  many 
other  arguments  might  be  brought  forward  to  prove  its  advisability  in 
some  subjects. 

(3)  The  view  is  held  that  710  examination  for  suspected  muscular 
error  in  the  orbit  should  be  regarded  as  conclusive  for  diagnosis,  or  as  a 
basis  for  any  surgical  procedure,  xmtil  the  eye  has  been  proven  to  be  free 
from,  refractive  error,  or  rendered  as  nearly  emmetropic  as  deemed 
advisable  by  properly  selected  glasses. 

It  is,  of  course,  advisable  during  the  first  interview  with  each 
patient  to  note  and  record  any  "  manifest  "  defect  in  sight.  If  such 
exists,  each  eye  should  be  provided  with  the  glass  which  gives  the  best 
vision  for  each  eye  (the  two  eyes  being  always  tested  independently  of 
each  other).  After  such  correction,  the  different  tests  employed  to 
detect  muscular  anomalies  should  then  be  made,  and  the  results  of  each 
test  should  be  recorded  as  the  "  manifest  muscular  error." 

At  the  second  interview,  with  the  pupils  fully  dilated  by  atroi^ine, 
the  same  steps  should  be  repeated.  We  thus  learn,  in  many  cases,  the 
existence  of  refractive  conditions  which  the  first  interview  did  not  reveal. 
We  record  such  as  "  latent  "  refractive  conditions.  By  the  aid  of  suitable 
glasses,  any  latent  refractive  error  found  is  then  to  be  corrected  ;  subse- 
quently, at  this  interview,  the  muscular  movements  are  to  be  tested  with 
each  eye  temporarily  adjusted  to  distant  vision  by  suitable  glasses. 


FUNCTIONAL  NEUROSES   AND  VISUAL  APPARATUS.  455 

(4)  The  view  is  held  that  all  tests  employed  to  detect  muscular 
anomalies  must  be  made  with  the  test-object  (preferal)ly  a  candle  flame)  at 
a  distance  of  at  least  twenty  feet  from  the  eye.  In  this  respect,  the 
method  of  conducting  examinations  advocated  here  is  somewhat  at 
variance  with  that  commonly  described  in  most  text-books. 

In  the  practical  ofiice  work  of  many  oculists  the  so-called  "  line  and 
dot  "  test  is  generally'  employed  (at  a  distance  of  fourteen  inches  from 
the  ej-e). 

It  is  usually  advisable  to  employ  this  test  in  addition  to  the 
"  candle  flame  "  test  at  twenty  feet ;  but,  when  it  is  emploj^ed,  the  results 
obtained  by  each  test  should  be  separately  recorded.  The  words  "  in 
accommodation "  have  been  suggested  by  Dr.  Stevens  as  a  suflflx  to 
designate  the  results  obtained  when  the  test-object  is  placed  at  fourteen 
inches  from  the  eye. 

While  it  is  deemed  desirable  in  most  instances  to  record  the  results 
of  both  tests  described  above,  all  operative  procedures  are  invariably 
based  upon  the  results  obtained  by  placing  the  test-object  at  a  distance 
of  twenty  feet  from  the  eye. 

To  a  lack  of  uniformity  in  the  tests  made  by  oculists  to  detect  mus- 
cular anomalies  in  the  orbit  many  of  the  discrepancies  frequently  met 
with  between  observations  made  by  different  men  upon  the  same  patient 
are  unquestionably  due.  For  example,  a  patient  may  exhibit  an  in- 
sutiieiency  of  the  externi  at  twenty  feet,  and  of  the  interni  at  fourteen 
inches,  in  spite  of  the  fact  that  all  precautions  have  been  taken  to 
previousl}^  rectify  existing  refractive  errors.  This  field  is  too  large  to 
discuss  here,  but  it  is  a  Axry  important  one.* 

(5)  The  view  is  held  that  obser-vations  made  for  muscular  anomalies 
in  the  orbit.,  when  the  test-object  is  within  the  limits  of  accommodation .,  are 
not  usually  reliable  as  a  basis  for  operative  procedure  undertaken  for  the 
relief  of  such  anomalies. 

Experience  goes  to  show  that  deviations  of  the  visual  axes  observed 
when  the  test-object  is  placed  at  twenty  feet  from  the  eye  more  correctly 
represent  the  muscular  error  which  needs  correction  in  any  given  case 
than  when  made  at  a  nearer  point. 

I  have  encountered  several  interesting  cases  where  extremely 
satisfactory  results  upon  functional  nervous  phenomena  of  a  distressing 
type  have  followed  an  operative  procedure  upon  the  eye-muscles,  which 
would  have  been  strongly  contra-indicated  if  I  had  attached  as  much 
importance  to  the  results  of  tests  made  with  the  test-object  at  fourteen 
inches  from  the  eye  as  the  statements  found  in  most  of  the  text-books 

*  See  articles  by  G.  T.  Stevens,  in  New  York  Medical  Jotirnal,  December,  1886,  and  in 
Archives  of  Ophthalmolof/y,  June,  1887;  also  a  paper  read  by  the  same  author  before  the 
luternational  Medical  Congress  at  Washington,  D.  C,  September,  1887. 


456  LECTURES   ON  NERVOUS   DISEASES. 

would  justify.  These  cases  impressed  me  very  strongly  at  the  time. 
They  bear  the  strongest  testimony  in  favor  of  the  view  that  convergence 
of  the  eyes  is  a  factor  which  should  be  eliminated  as  far  as  possible  in 
searching  for  muscular  anomalies  of  the  orbit. 

(6)  The  view  is  held  that  muscular  anomalies  in  the  orbit  may  be 
partially  or  totally  ^'■latent.'''' 

The  amount  of  muscular  error  detected  in  any  given  case  does  not 
necessarily  indicate  the  full  amount  of  error  that  actually  exists. 

The  results  of  ordinary  tests  simply  tell  us  how  much  eye-tension 
exists  which  the  patient  cannot  overcome  by  any  effort  of  which  he  is 
capable. 

Upon  this  one  point  too  great  stress  cannot  be  laid,  as  it  sheds  much 
light  upon  the  clinical  history  of  many  patients  who  suffer  from  eye- 
strain. 

All  authorities  recognize  the  fact  to-da}^  that  a  patient  may  have  a 
very  marked  congenital  shallowness  of  the  eye,  and  apparentlj'  have 
normal  vision,  or  possibly  appear  to  be  even  near-sighted,  prior  to  the 
use  of  atropine.  Subsequently  to  its  use,  the  same  patient  will,  however, 
show  a  high  degree  of  far-sightedness  (hypermetropia),  because  the  ciliary 
muscle  (temporarily  paralyzed  by  the  atropine)  cannot  overcome,  or  (to 
speak  more  technically)  compensate  for  the  abnormal  shallowness  of 
the  eye. 

Unfortunately  for  science,  we  have  as  yet  no  drug  which  aids  us  in 
determining  the  existence  of  a  ''  latent  "  muscular  error  in  the  orbit. 

Yet,  are  we  justified  in  concluding  that  latent  mvTscular  anomalies  do 
not  exist?  Most  assuredly  not.  There  is  the  strongest  clinical  evidence 
to  the  contrary. 

Only  a  few  weeks  ago,  I  examined  the  eyes  of  a  prominent  physician 
on  three  consecutive  days,  and  I  was  unable  to  detect  (either  before  or 
after  prismatic  exercise  of  his  eye-muscles)  an}"  change  in  his  ocular 
condition  from  the  one  noted  at  the  first  examination.  His  symptoms, 
however,  led  me  to  believe  that  a  greater  muscular  error  existed  than  he 
showed,  although  the  anomaly  detected  was  a  very  marked  and  im- 
portant one. 

I  therefore  instructed  him  to  wear  a  prism,  which  nearly  corrected  the 
error  then  detected,  until  the  next  examination.  Less  than  two  hours 
later,  I  accidentally  had  the  opportunity  of  again  examining  his  eyes. 
His  muscular  error  was  then  exactly  doultle  what  it  originally  appeared 
to  be.  He  was  again  given  almost  a  full  prismatic  correction  for  the 
defect  detected.  Twenty-four  hours  later  he  was  examined  for  the  fifth 
time,  and  he  still  showed  an  excess  of  two  degrees  over  the  record  of 
the  day  previous.  He  was  again  given  a  further  prismatic  correction; 
but  from  that  time  he  fjiiled  to  exhibit  any  further  alteration  in  his  ocular 


FUNCTIONAL  NEUROSES   AND  VISUAL   APPARATUS.  457 

tests.  The  relief  aflbrded  by  prisms  was  so  instantaneous  and  permanent 
(wiiile  they  were  worn)  as  to  prove  conclusively  that  the  prisms  were 
wisely  selected,  and  that  the  "latent  "  insufficiency,  which  was  developed 
after  and  by  means  of  their  use,  more  accurately  represented  his  true 
condition  than  did  the  original  observations  made  at  the  first  interview. 

I  mention  this  case,  not  because  it  is  at  all  unique  (for  many  such 
instances  have  been  observed)  but  because  it  illustrates  admirably  the 
existence  of  latent  insufficiency,  which  happened  in  this  case  to  be 
developed  rapidl}^  by  the  temporary  use  of  correcting  prisms. 

In  the  second  place,  it  is  not  at  all  uncommon  to  observe  the 
development  of  latent  muscular  anomalies  in  the  orbit  after  a  graduated 
tenotomy  has  been  satisfactorily  and  scientifically  performed  for  the 
correction  of  a  '"manifest"  muscular  error.  Sometimes,  quite  a  long 
interval  elapses  before  latent  insufficiency  shows  itself.  Again,  it  shows 
itself  almost  immediately. 

An  epileptic,  upon  whom  I  operated  for  eye-defect,  and  who  has 
now  been  free  from  attacks  for  over  one  year  and  a  half,  in  spite  of  the 
cessation  of  all  drugs,  showed  me  originally  only  one  degree  of  esophoria. 
This  defect  would,  I  think,  have  been  heretofore  regarded  bj^  most 
oculists  as  hardly  worthy  of  correction — even  by  a  prism.  The  sub- 
sequent treatment  of  this  case  demanded  repeated  partial  tenotomies 
upon  both  of  the  interni ;  and  proved  not  only  that  I  had  a  high  degree 
of  "latent"  trouble  to  correct  (which  a  one-degree  prism  would  not  haA'e 
helped),  but  also  that  the  attacks  have  thus  far  been  totally  arrested  by 
the  relief  of  abnormal  eye-tension. 

In  the  third  place,  it  has  been  proven  that  systematic  daily  exercises 
of  the  various  eye-muscles  (accomplished  b}*  teaching  the  patient  to  fuse 
images  which  have  been  rendered  momentarily  double  by  a  prism  held 
before  the  eyes)  will  in  some  cases  develop  latent  muscular  anomalies  of 
the  orbit. 

In  other  words,  a  patient,  after  a  week's  muscular  drill,  will  often 
show  a  greater  flexibility  of  the  eye-muscles  and  the  existence  of  a  lack 
of  equilibrium  in  the  ej'e-movements,  which  the}^  did  not  exhibit  at  the 
earlier  examinations.  I  am  aware  that  an  injudicioiis  use  of  such 
prismatic  tests  in  the  hands  of  a  novice  might  cause  "  asthenopia," 
and  seriously  affect  muscular  conditions  ;  but  this  fact  can  hardly  be 
used,  I  think,  by  fair-minded  critics,  to  explain  the  phenomena  alluded 
to  here. 

Finally,  it  may  be  stated,  in  this  connection,  that  one  examination 
of  the  various  eye-movements  is  not,  as  a  rule,  sufficient  for  a  positive 
diagnosis  respecting  muscular  anomalies.  Repeated  tests  have  often  to 
be  made  before  a  complicated  problem  may  be  satisfactorily  solved,  even 
by  an  expert  in  this  line  of  examination. 


458  LECTUEES   ON   NERVOUS   DISEASES. 

(7)  The  view  is  held  that  prismatic  glasses  are  not  onhj  inadequate 
as  satisfactory  remedial  agents  in  most  cases,  but  that  they  may  be  jjosi- 
tively  injurious  to  certain  classes  of  patients. 

Few,  if  anj',  of  our  prominent  oculists  have  perhaps  ordered  as 
many  prismatic  glasses  as  has  the  chief  advocate  of  the  method  now 
under  discussion.  Yet,  in  spite  of  this  fact,  strict  limitations  upon  their 
field  of  usefulness  (not  generally  taught)  seem  to  be  rendered  probable 
by  late  investigations. 

A  careful  study  of  the  different  movements  of  the  eyeball,  and  of 
the  combination  of  muscles  required  to  produce  some  of  them,  must 
impress  even  the  most  casual  reader  with  the  idea  that  an  agent  (such, 
for  example,  as  a  strong  prism)  which  tends  to  restrict  the  movements 
of  any  one  muscle,  may  do  harm  if  persistently  worn. 

Some  patients  are  peculiarly  susceptible  to  such  influences.  I  have 
encountered  a  large  number  of  patients  whose  eyes  refused  to  tolerate  a 
prismatic  glass.  Their  symptoms  were  at  once  made  worse  whenever 
they  attempted  to  correct  an  existing  muscular  anomaly  by  wearing  a 
prismatic  glass. 

On  the  other  hand,  many  patients  are  benefited  at  once  by  the  use 
of  prisms,  and  suflTer  no  inconvenience  of  any  kind  from  them. 

What  are  we  to  infer  from  tliis  statement?  Are  we  to  surmise  that 
the  prisms  were  either  injudiciousl}'  selected  or  improperly  placed, 
simply  because  the  patient  could  not  tolerate  them  ?  I  think  not.  Such 
might  possibly  be  the  case  in  the  hands  of  a  novice,  but  presumably  it 
is  not  the  case  in  the  experience  of  one  skilled  in  e^'e-examinations. 

My  own  experience  in  several  such  instances  has  shown  me  that  a 
properl}'  graduated  tenotomy  of  the  muscle  exhibiting  the  greatest  tension 
has  been  followed  by  a  complete  cessation  of  the  nervous  sj-mptoms  for 
which  the  patient  sought  relief,  in  spite  of  the  fact  that  prisms  prescribed 
to  correct  the  same  error  have  proved  intolerable  to  the  patient,  and 
have  markedly  aggravated  the  symptoms. 

There  is,  however,  a  practical  and  important  field  for  prismatic 
glasses.  It  is  well  to  keep,  as  a  part  of  a  physician's  office  equipment,  a 
large  number  of  prisms  of  different  angles.  These  can  be  slipped  into 
a  frame  with  the  base  inward,  outward,  upward  or  downward,  as  the 
exigencies  of  any  case  seem  to  demand.  They  may  be  loaned  from  time 
to  time  to  patients,  for  the  purpose  either  of  verif^ying  a  diagnosis  or,  by 
giving  relief  to  a  "  manifest  "  ocular  tension,  of  developing  a  latent 
muscular  error  which  the  ph^'sician  may  be  led  (by  repeated  examinations 
of  the  patient)  to  suspect.  When  they  ai-e  well-tolerated,  the  physician 
may  often  learn  a  great  deal  by  their  protracted  influence.  When  they 
are  not  well  borne,  it  is  advisaljle,  as  a  rule,  to  discontinue  their  use  at 
once. 


FUNCTIONAL   NEUROSES   AND   VISUAL   APPAEATUS.  459 

It  is  often  wise  to  prescribe  prismatic  glass,  also,  for  a  class  of 
patients  who  are  unable  (for  one  reason  or  another)  to  submit  at  the 
ti)ne  to  a  graduated  tenotoni}'. 

Sooner  or  later,  I  find  that  such  patients  usually  return.  As  a  rule 
they  do  so  for  one  of  the  following  reasons:  (1)  because  the}'  have 
developed  an  additional  "latent"  muscular  error,  which  the  prisms 
naturally  failed  to  correct;  (2)  because  they  do  not  tolerate  them  well, 
and  are  made  decidedly  worse  by  their  use;  (3)  because  they  prefer  a 
tenotomy  to  the  inconvenience  of  a  glass  which  has  to  be  constantly 
worn;  and  (4)  because  they  suffer  from  eye-fatigue,  on  account  of  tlie 
disturbance  to  coordinate  movements  of  the  eyeball. 

There  is  no  doubt  that  very  many  cases  of  nervous  diseases  are 
materially  helped  (if  not  radically  cured)  by  the  aid  of  prismatic  glasses; 
but  the  question  naturally  arises  to  my  mind  in  this  connection,  "  Would 
the}'  not  have  been  more  rapidly  benefited  and  permanently  relieved  with 
far  less  inconvenience  to  the  patient  by  tenotomy?" 

(8)  The  view  is  held  that  a  graduated  tenotomy  is  the  only  way  of 
satisfactorily  and  permanently  relieving  abnormal  tension  of  a  muscle  in 
the  orbit. 

There  are  only  two  ways  of  overcoming  an  abnormal  tendency  of 
the  visual  axes  to  deviate  from  parallelism  whenever  the  e^-es  are  directed 
upon  an  object  more  than  twenty  feet  off".  One  of  these  is  by  the  aid  of 
a  prism;  the  other  is  by  a  graduated  tenotomy  of  the  muscle,  whicli 
directly  aids  in  producing  and  perpetuating  the  deviating  tendency. 

AVhenever  prisms  are  prescribed,  they  afford  relief  practically'  in  the 
same  way  as  a  "rubber  muscle"  does  in  orthopaedic  surgery;  in  other 
words,  they  compel  the  muscle  which  is  opposed  to  the  base  of  the  prism 
worn  b}'  the  patient  not  onl}'  to  overcome  the  antagonistic  muscle,  but 
also  to  so  adjust  the  e.ye  as  to  compensate  for  the  refractive  effect  of 
the  prism.  The}'  practically  act,  therefore,  as  a  "  pulley -weight " — a' 
mechanical  device  seen  in  all  gymnasiums. 

Now,  if  the  wearing  of  prisms  had  no  deleterious  action  upon  those 
particular  muscles,  which,  in  each  case,  are  not  at  all  at  fault,  and  if 
they  invariabl}'  exerted  only  beneficial  effects,  this  principle  of  treatment 
could  be  more  generally  applied  with  benefit.  Even  then,  the  existence 
of  latent  insuthciency  might,  unfortunateh',  remain  unrecognized  for  a 
greater  or  less  period  of  time,  possibl}'  to  the  serious  detriment  of  the 
patient.  On  the  other  hand,  if  it  be  satisfactorily  demonstrated  that 
tlie  operation  termed  "  graduated  tenotomy  "  has  been  rendered  a  safe 
and  accurate  method  of  correcting  muscular  anomalies  in  the  orbit,  a 
fact  has  certainly  been  noted  that  opens  a  new  and  shorter  route  to  reliel". 
Such  a  step  enables  us,  moreover,  to  decide  the  question  of  "  latent  " 
muscular  defects  in  any  given  case. 


460  LECTURES   ON   NERVOUS   DISEASES. 

(9)  The  view  is  held  that  the  difficulties  j)revinusly  experienced  in 
attempting  to  correct  so-called  '■'■  muscular  insufficiencies''''  in  the  orbit  by  a 
surgical  procedure  uponthe  stronger  muscles  have  now  been  satisfactorily 
overcome. 

Space  will  not  permit  of  a  discussion  here  of  the  demerits  of  oper- 
ations previously  devised  for  this  purpose.  Suflice  it  to  say  that  the 
operation  first  su<^gested  and  performed  by  my  friend,  Dr.  G.  T.  Stevens, 
preserves  the  normal  line  of  traction  of  the  muscle. 

This  is  a  point  of  vital  importance  to  the  patient,  and  one  which 
cannot  be  claimed,  in  m}^  opinion,  for  any  other  operation  previously 
devised  for  this  purpose  with  which  I  am  familiar. 

Any  disturbance  in  the  pi'oper  adjustment  of  the  ej^e-muscles,  which 
must  ensue  from  an  alteration  in  the  line  of  traction  of  any  one  or  more 
of  the  six  muscles  which  move  the  e^^e,  cannot  help  but  be  a  serious 
matter. 

The  full  details  of  the  operation  alluded  to  have  already  been 
published.*  I  quote  from  an  article  lately  read  before  the  Neurological 
Society  of  New  York  by  the  chief  advocate  of  this  method : — 

"  In  the  main  it  consists  of  making  a  small  opening  through  the 
conjunctiva,  exactly  over  the  insertion  of  the  tendon,  when  the  tendon 
is  seized  by  extremely  fine  foi-ceps,  and  divided  in  each  direction, 
preserving  the  extreme  outer  fibres,  or,  at  least,  the  reflection  of  the 
capsule  of  Tenon,  which  serves  as  an  auxiliary  attachment." 

It  may  be  stated  in  this  connection  that  this  operation  is  absolutely 
painless  when  done  under  the  influence  of  cocaine;  that  stitches  are 
never  employed ;  that  no  subsequent  dressings  are  rendered  necessary ; 
and  that  patients  frequently  go  from  the  operating  chair  directly  to  their 
business.  A  slight  amount  of  redness  and  irritation  about  the  wound, 
and  occasionally  some  sub-conjunctival  hemorrhage  (both  of  which  tend 
to  rapidly  disappear)  are  all  the  inconveniences  which  this  operation 
commonly  entails.  I  have  personally  performed  this  operation  about 
six  hundred  times  up  to  the  present  date,  and  I  have  never  known 
suppuration  to  occur,  or  an}^  complications  to  be  induced  which  caused 
me  serious  perplexity. 

(10)  The  view  is  held  that  '■'■  eye-strain"  from  any  cause  (be  it 
refractive  or  muscular)  is  a  serious  matter,  and  that  its  tendency  is  to 
predispjose  to  nervous  derangements  and  to  perp)etuate  them  ichen  once 
developed  so  long  as  this  factor  ea:ists. 

This  is  one  of  the  most  impoi-tant,  if  not  the  chief  claim  made. 
It  is  substantiated  by  manj^  carefully  made  and  collected  observations. 

It  is  chiefly  in  those  cases  where,  in  spite  of  a  muscular  error,  the 
images  of  the  two  ej'es  can  be  blended  by  a  great  effort  that  the  patient 

*  Archives  of  Ophthalmology,  June,  1887, 


FUNCTIONAL  NEUROSES   AND   VISUAL  APPARATUS.  461 

begins  to  experience  the  deleterious  pliysiciil  influences  of  abnormal 
muscular  tension  in  the  orbit.  Placing  a  plain  red  ghiss  before  one  e3e 
of  a  patient  suspected  of  having  a  slight  degree  of  strabismus  will  often 
reveal  to  a  patient  a  diplopia  of  which  he  or  she  may  have  been  un- 
conscious. Sucli  cases  do  not  belong  to  the  class  discussed  here  as 
those  of  "  insutiiciency  of  the  ocular  muscles." 

It  is  not  hard  to  understand  why  it  is  that  an  animal  too  heavily 
laden  is  unable  to  rise  after  a  fall  has  occurred  until  the  load  is  taken 
from  it. 

So  it  is  with  many  nervous  patients.  The  incessant  efforts  made  to 
fuse  the  images  perceived  by  the  two  eyes  into  a  single  image  (when  a 
muscular  defect  renders  such  an  act  possible,  yet  one  of  extreme  diffi- 
culty) are  liable  sooner  or  later  to  exhaust  the  nervous  force  of  the  patient 
and  to  excite  some  form  of  functional  nervous  disturbance. 

This  is  the  line  of  argument,  which  apparently  seems  difficult  to 
understand.  It  is  a  train  of  reasoning  which  many  enthusiastic  patliolo- 
gists  naturally  prefer  to  discard,  because  it  puts  an  end  to  a  search  for  a 
pathognomonic  lesion  which  no  human  eye  (even  with  the  aid  of  a 
microscope)  has  ever  yet  been  able  to  detect  in  many  hopeless  and 
chronic  cases  of  chorea,  epilepsy,  insanity,  neuralgia,  headache,  hysteria, 
and  neurasthenia.  It  is  a  view  which  will  probably  be  opposed  by  some, 
because  it  comes  into  direct  antagonism  with  the  prolonged  administration 
of  the  various  bromide  salts;  in  spite  of  the  fact  that  the  injurious  effects 
of  such  administration  are  too  frequently  encountered  to  be  ignored.  It 
is  a  principle  relating  to  functional  neuroses  which  is  naturally  combated 
on  general  grounds,  because  it  is  new,  and  opposed  to  preexisting  views. 

Respecting  the  views  here  advanced,  I  take  the  liberty  of  quoting  a 
few  selected  paragraphs  from  a  singularly  lucid  paper  lately  read  by  the 
pioneer  in  this  field  before  the  Neurological  Society  of  New  York.*  1 
do  so  because  they  appear  even  yet  to  be  misunderstood  by  some  who 
listened  to  the  paper  quoted  fi'om.     The  author  of  that  paper  says : — 

"  A  doctrine  so  much  at  variance  with  ordinary  beliefs  must  of 
necessity  excite  suspicion  that  the  proposition  has  been  based  upon 
insufficient  data,  or  that  observations  have  been  imperfectly  made.  That 
neither  of  these  suspicions  is  correct  it  is  hoped  may  be  shown  to  the 
satisfaction  of  reasonable  inquirers.  If  the  proposition  appears  extreme, 
and  tending  at  best  to  the  recognition  of  a  single  class  of  causes  to  the 
exclusion  of  others,  let  me  recall  the  fact  that  the  proposition  fully 
recognizes  an}^  and  all  causes  of  nervous  irritation,  and  that  the  influ- 
ences indicated  are  held  to  be  preeminent,  but  not  exclusive  permanent 
causes.  If  greater  importance  is  conceded  to  the  influences  mentioned 
in  the  proposition  than  to  others,  it  is  from  no  nnmindfulness  of  the 

*  New    York  Medical  Journal,  April  16,  18S7. 


462  LECTURES   ON   NERVOUS  DISEASES. 

possibility  of  other  conditions  acting  as  irritating  influences,  or  that  cer- 
tain known  or  unknown  influences  may  give  character  to  the  results  of 
irritation  arising  from  the  causes  mentioned.  Let  it  be  remembered 
that  it  has  been  universally  conceded  that  the  nature  of  the  neuropathic 
tendency  is  unknown.  If  one  preeminently  important  element  is  de- 
monstrated, it  is  not  to  be  rejected  because  it  may  not  include  the 
whole. 

"  In  the  explanation  of  the  etiology  and  treatment  of  disease,  neither 
settled  theories  nor  novel  doctrines  are  to  be  accepted  only  as  they  are 
confirmed  by  undoubted  facts.  Nor  can  isolated  facts,  nor  facts  divested 
of  their  natural  environments,  be  accepted  as  valid  evidence  in  support 
of  theories,  old  or  new.  The  facts  must  be  uniform,  occurring  so  regu- 
larly as  sequences  as  to  demonstrate  that  they  are  consequences. 
Unless  the  skilled  observer  is  able  to  predict,  with  a  reasonable  degree 
of  accuracy,  the  result  of  certain  combinations  of  circumstances,  such 
result,  when  occurring,  must  be  considered  accidental." 

"  The  principle  of  ocular  irritation  is  of  wide  application,  and  is  not 
to  be  compared  with  the  occasional  irritation  set  up  by  such  accidental 
and  usually  secondar}^  causes  as  phimosis  is,  the  presence  of  calculus,  the 
existence  of  a  stricture  of  a  passage,  the  etfects  of  decaj-ed  teeth,  and  of 
many  other  peripheral  irritations  which  might  be  mentioned.  All  these 
are  of  importance,  and  are  not  to  be  overlooked. 

"  The  conditions  to  which  I  have  especially  called  attention  are, 
however,  in  general,  commensurate  with  the  life  of  the  patient,  and  exist 
in  a  vastly  greater  number  of  instances  than  either  or  all  of  the  condi- 
tions belonging  to  the  other  class  just  mentioned.  Not  only  are  those 
painful  or  irregular  conditions,  usually  described  as  neuroses,  in  great 
proportion  responsive  to  the  relief  from  ocular  tensions;  but  a  great 
variety  of  conditions,  commonly  regarded  as  local  affections,  jield  as 
readily,  and  prove  that  they  are  in  fact  reflex  phenomena. 

"  If  it  be  said  that  the  origin  and  prevention  of  nervous  diseases  is 
to  be  found  in  a  great  variety  of  circumstances,  I  repl}'^,  let  us  find  them 
all,  and  adapt  our  measures  to  them  all,  but  let  us  not  neglect  this 
because  there  may  be  others. 

"  For  m3' self,  I  do  not  think  that  another  as  important  class  of 
causes  of  nervous  disturbance  will  be  found  as  that  which  attends  the 
anomalies  of  the  parts  engaged  in  the  performance  of  the  visual  function. 
In  any  case,  our  aim  is  to  prevent  the  evils  of  nervous  derangement  bj- 
the  early  removal  of  any  known  mischievous  tendency,  and  our  duty  is, 
when  such  nervous  derangement  actually  occurs,  to  remove  every  per- 
plexing cause.  In  the  observance  of  such  a  principle,  we  may  leave  to 
superstition  and  to  ignorance  the  practice  of  expelling  nervous  diseases 
b}'  means  either  fashionable  or  obsolete." 


FUNCTIONAL   NERVOUS   DISEASES   AND   REFLEX   CAUSES.       463 


are  functional   nervous  diseases    frequently    reflex 
manifestations! 

The  view  that  a  direct  relationship  exists  in  many  subjects  between 
epileptic  seizures  (that  are  apparently  not  associated  with  organic  lesions 
of  the  brain)  and  abnormal  muscular  tension  within  the  orbit  seems  to 
have  received  most  valuable  indirect  confirmation  in  the  startling 
experiments  published  b3'  Drs,  F.  X.  Dercum  and  A.  J.  Parker,  of  the 
University  of  Pennsylvania.*  According  to  these  observers,  convulsive 
seizures  were  artificially  induced  in  apparently  healthy  subjects  by 
prolonged  muscular  tension  of  a  single  muscle  or  groups  of  muscles  in 
the  limbs. 

I  regard  these  experiments  as  perhaps  the  most  important  ones  that 
have  yet  been  brought  forward  in  support  of  the  general  view  that 
epileptic  seizures  are,  in  the  large  proportion  of  cases,  simply  one  of  the 
many  types  of  manifestation  that  a  reflex  cortical  disturbance  is  capable 
of  exhibiting. 

It  is'  unquestionably  true  also  that  such  reflex  causes  are  too 
often  not  sought  for  by  the  profession  with  suftlcient  care  or  in  the 
proper  way. 

The  methods  of  examination  that  have  been  generally  regarded  until 
of  late  as  conclusive,  when  defects  in  adjustment  of  the  eye-muscles 
have  casually  been  sought  for,  were  certainly'  most  crude  and  unscientific; 
and  a  modification  of  them  appears  to  be  most  timely. 

I  take  the  liberty  of  quoting  from  the  published  experiments  of 
Drs.  Dercum  and  Parker  the  following  paragraphs: — 

"  The  subject  being  seated,  the  tips  of  the  fingers  of  one  or  both  hands  were  so 
placed  upon  the  surface  of  a  table  as  to  give  merely  a  delicate  sense  of  contact,  i.e.,  the 
fingers  were  not  allowed  to  rest  upon  the  table,  but  were  Tnaintained,  by  a  constant  ynuscular 
effort,  barely  in  contact  with  it.-f  Any  other  position  involving  a  like  effort  of  constant 
muscular  adjustment  was  found  to  be  equally  efiicient.  Any  one  object  in  the  room  was 
now  selected,  and  the  mind  fixed  upon  it,  or  some  subject  of  thought  was  taken  up  and 
unswervingly  followed. 

"  After  the  lapse  of  a  variable  period  of  time,  extending  from  a  few  minutes  to  an 
hour,  and  depending  upon  individual  peculiarities  to  be  noted,  ....  the  subject  was 
frequently  thrown  violently  to  the  ground  in  a  general  convulsion,  preceded  by  tremors 
which  rapidly  became  more  violent. 

"  Seizures  equalling  in  violence  a  general  convulsion  were  by  no  means  induced  in  all 
subjects,  and  were  generally  the  result  of  experiments  repeated  many  times  during  the 
same  evening.  In  the  experimenters  the  convulsions  became  so  easily  induced  that  it  was 
thought  advisable  to  desist  for  a  long  period." 

*  Jour,  of  Nervous  and  Mental  Diseases,  1884,  pp.  579  and  636. 
t  Italics  my  own. 


464  LECTURES   ON   NERVOUS   DISEASES. 

Dr.  Chas.  H.  Thomas,  of  Philadelphia,  when  speaking  of  these 
experiments  in  a  late  contribution  to  this  subject,*  says  : — 

"  Tlie  effort  of  constant  muscular  adjustment  here  spoken  of  appears  not  unlike 
the  condition  found  in  the  eyes  in  cases  of  insufficiency  of  the  ocular  muscles;  and 
it  seems  not  unreasonable  to  infer  that  if  such  strain  of  the  muscles  of  the  forearm 
would  produce  results  of  the  kind  reported  by  the  authors  just  named,  that  the  strain 
upon  ill-balanced  ocular  muscles  (which  must  be  continuous  during  the  whole  of  the 
time  that  the  eyes  are  opened)  should  be  productive  of  even  more  serious,  and,  indeed, 
permanent  results." 

Within  the  past  year,  an  extremely  valuable  paper  respecting 
one  of  the  much  neglected  and  perhaps  not  infrequent  causes  of 
epilepsy  has  been  also  published  by  Dr,  A.  P.  Brubaker,f  of  Phila- 
delphia, entitled  "  Dental  Irritation  as  a  Factor  in  the  Causation  of 
Epilepsy."  The  following  extracts  from  this  paper  have  an  impor- 
tant clinical  bearing,  and  possibly  shed  some  light  upon  the  proper 
treatment  of  convulsive  diseases  and  other  forms  of  reflex  nervous 
conditions : — 

"  In  all  the  wide  divergence  of  view  as  regards  the  nature  of  epilepsy  there  is  a 
general  consensus  of  opinion  that  its  essential  feature  is  of  the  character  of  an  explosive 
discharge  from  the  higher  nerve-centres,  the  nerve-force  thus  liberated  bearing  down  upon 
the  centrifugal  distributions  of  the  motor  nerve-tracks  with  such  an  excess  of  energy  that 
incoordination  of  movement  reaches  the  stage  of  convulsion  and  spasm.  Owing  to  the 
periodicity  of  the  convulsive  seizures,  it  has  been  assumed  that  in  individuals  predisposed 
to  epileptic  attacks  the  higher  nerve-centres  are  in  a  state  of  high  tension,  of  unstable 
equilibrium,  and  that  it  only  requires  a  stimulus  of  a  definite  quantity  or  intensity  to 
excite  the  explosive  discharge. 

"  The  object  of  this  paper  is  to  direct  the  attention  of  pihysicians  to  a  cause  of  epilepsy 
which  has  not  hitherto  been  estimated  at  its  full  value,  inasmuch  as  in  none  of  the  standard 
works  u[)On  neurology  is  the  subject  even  alluded  to, — viz.,  pathological  states  of  the  dental 
structures.  That  dental  inflammations  and  disorders  are  more  often  provocative  of 
epileptic  seizures  than  is  commonly  supposed  appears  quite  certain  from  the  following 
cases,  and  also  from  the  character  of  the  cause  and  its  effect.  Many  reasons  might  be 
given  why  dental  disorders  are  peculiarly  adapted  to  call  forth  this  periodical  discharge, 
and  why  these  disorders  are  habitually  overlooked  by  the  physician,  but  they  need  not  be 
detailed  here.  As  exemplifying  these  phenomena,  some  interesting  and  instructive  cases 
are  adduced. 

"  The  interest  aroused  by  the  result  of  the  preceding  case  led  to  an  examination  of 
medical  literature  for  reports  of  similar  cases.  I  find  that  no  less  than  sixteen  cases, 
entirely  and  immediately  cured  by  the  removal  of  an  irritating  tooth,  have  been 
recorded  by  different  observers,  and  which  are  here  arranged  in  chronological  order. 
It  is  not  supposed  that  this  collection  embraces  all  the  recorded  cases,  but  it  is  hoped 
that  it  will  elicit  references  to  many  others,  and,  what  is  more  important,  the  reporting 
of  many  new  cases." 

*  Trans.  Phila.  Co.  lied.  Soc,  Mar.  14,  1888. 

t  Jo^^r.  of  Nervous  and  Mental  Diseases,  1888,  p.  117. 


FUNCTIONAL   NERVOUS   DISEASES   AND   REFLEX   CAUSES.       465 

111  the  light  shed  upon  this  subject  chiefly  b}'  recent  contributions 
to  medical  literature,*  the  view  is  graduall}^  being  accepted  b^'  many  in 
the  profession  that  certain  nervous  diseases  (whose  pathology,  to  say  the 
least,  is  still  in  doubt)  are  possibly  not  dependent  in  every  case  upon  an 
unrecognized  organic  lesion  ;  and  they  are  being  led  to  coincide  with 
the  statement  that  the  term  "  functional "  nervous  disease  may  be 
properly  applied,  in  some  instances  at  least,  to  the  graver  nervous 
conditions, — such,  for  example,  as  epilepsy,  chorea,  hysteria,  or  other 
manifestations  of  nervous  exhaustion,  and  insanity.  In  other  words, 
the  professional  mind  seems  more  willing  now  than  in  the  past  to  discard 
an  apparently  fruitless  search  for  a  pathognomonic  lesion  for  each 
intractable  nervous  condition,  and  to  look  more  calmly  upon  tangible 
clinical  facts,  even  if  they  are  radically  opposed  to  preexisting  views. 

If  the  view  that  eye-strain,  dental  irritation,  or  other  causes  of  reflex 
disturbance  may  be  a  frequent  cause  of  functional  nervous  derangements 
proves  to  be  the  correct  one,  beyond  the  possibility  of  doubt  or  cavil, 
it  is  not  diflicult  to  see  that  a  hope  of  marked  relief  or  of  ultimate 
recovery  is  practically  extended  to  manj'  hopeless  sufferers  upon  whom 
drugs  have  exerted  little  or  no  benefit. 

In  order  that  those  of  my  readers  who  have  possibly  not  given 
much  attention  to  the  views  which  most  of  my  incorporated  cases  are 
particularly  selected  to  illustrate  ma^^  properly  understand  the  train  of 
reasoning  that  offered  a  solution  to  1113'  mind  of  the  symptoms  here 
recorded,  I  take  the  liberty  of  quoting  a  few  paragraphs  from  a  paper 
which  I  lately  read  before  the  International  Medical  Congress  at 
Washington,  entitled  "  Does  a  Relationship  Exist  between  Anomalies  of 
the  Visual  Apparatus  and  the  So-called  '  Neuropathic  '  Predisposition  ?"f 
This  paper  was  based  upon  a  carefully  tabulated  analj^sis  of  the  records 

*The  reader  is  referred  to  the  articles  by  Dr  George  T.  Stevens  on  "Chorea" 
(Medical  Record,  1S76);  on  "  Anomaliesof  the  Ocular  Muscles  "  (Arch,  of  Ophthalmology, 
June,  1877);  and  on  "Ocular  Irritations  and  Nervous  Diseases"  (New  York  Medical 
Journal,  April,  1877);  also  to  his  work  on  "Functional  Nervous  Diseases"  (D.  Appleton 
&  Co.,  N.  Y.,  1887);  also  to  a  contribution  by  Dr.  H.  D.  Noyes,  on  "  Tests  for  Muscular 
Asthenopia  and  Insufficiency  of  the  External  Recti,"  read  by  him  before  the  International 
Medical  Congress,  Copenhagen,  1884;  also  to  papers  by  the  author  on  "The  Eye  as  a 
Factor  in  the  Causation  of  Some  Common  Nervous  Symptoms  (JVew  York  Medical  Jo7irnal, 
February  27  and  March  15,  1886);  on  "Eve-strain  in  Neurology"  (Ncui  York  Medical 
Journal,  April  16, 1887) ;  on  "  Eye-strain  in  its  Relations  to  Functional  Nervous  Diseases  " 
(Medical  Bulletin,  September,  1887);  and  an  abstract  of  an  essay  read  before  the 
International  Medical  Congress  at  Washington,  entitled  "  Does  a  Relationship  Exist 
Between  Anomalies  of  the  Visual  Apparatus  and  the  So-called  '  Neuropathic  Predisposi- 
tion V  "  (Medical  Register,  November  19,  1887).  The  articles  by  Drs.  Dercum  and  Parker, 
Dr.  C.  H.  Thomas,  and  Dr.  A.  P.  Brubaker,  of  Philadelphia  (already  quoted),  are  worthy 
of  special  notice  in  this  connection.    " 

t  An  abstract  of  this  paper  was  published  in  the  Medical  Register,  November  19, 
1887. 

80 


466  LECTURES   ON   NERVOUS   DISEASES. 

of  one  hundred  consecutive  cases  of  typical  neuroses  taken  from  my 
private  case-book. 

in  this  paper  I  say  : — 

Until  tliure  is  a  uniformity  in  the  mfthods  employed  for  testing  the  eye-muscles* 
and  of  terms  for  the  recording  of  anomalies  so  detected,  the  profession  must  unfortunately 
continue  to  be  more  or  less  embarrassed  in  this  line  of  research.  I  do  not  feel  justified  in 
personally  discussing  this  subject  here,  as  it  has  only  an  indirect  relationship  with  this 
paper;  but  I  can  not  refrain  from  saying,  in  this  connection,  that  to  defective  methods  of 
examination,  made  venerable  chiefly  by  their  antiquity,  we  owe  to-day,  in  my  opinion, 
much  of  our  ignorance  of  anomalies  of  the  ocular  muscles. 

Some  time  ago  I  was  struck,  on  looking  over  a  children's  magazine,  with  an  illustra- 
tion designed  to  teach  the  reader  the  dependence  of  the  various  organs  of  the  body  upon 
the  brain.  It  represented  the  brain  as  the  head  of  a  manufacturing  establishment  sitting 
at  his  desk,  and  around  him  were  the  various  departments, — as,  for  example,  the  liver- 
department,  the  stomach-department,  the  eye-department,  etc.  These  departments  were 
connected  with  the  head  of  the  establishment  (the  brain)  by  telegraph-wires,  through 
which  each  could  make  its  wants  known  and  receive  information  regarding  them. 

Probably  the  designer  of  this  sketch  (made  for  the  purpose  of  illustrating  to  the 
child  the  dependence  of  the  organs  upon  the  brain  for  their  successful  operation,  as  well 
as  their  actual  support)  built  "better  than  he  knew."  He  embodied  in  his  drawing  a 
graphic  representation  of  certain  fundamental  principles  of  physiology  which  are  not 
clearly  understood  even  by  many  adult  minds  in  their  bearings  upon  the  general  health. 

The  lungs  do  not  make  us  breathe ;  except  in  an  indirect  way,  by  asking  the  brain 
to  start  the  necessary  muscles  into  action.  The  stomach  does  not  perform  its  functions 
until  after  the  brain  has  been  requested  by  it  to  turn  on  the  blood-supply  in  sufficient 
quantities  to  produce  the  requisite  quantity  of  gastric  juice.  The  intestine  performs  its 
incessant  worm-like  movements  by  no  inherent  power  of  its  own.  The  heart  keeps  up  its 
rhythmical  beating  only  when  permitted  to  do  so  by  the  great  centre  of  nerve-force. 

Now,  is  it  at  all  inconsistent  with  physiological  principles  to  advance 
the  view  that  any  excess  of  nervous  expenditure  to  one  organ  over  the 
normal  amount  which  should  be  furnished  is  done  at  the  expense  of 
the  others  sooner  or  later  ? 

No  one  can  draw  incessantly  upon  his  reserve  capital  of  nerve-force 
without  incurring  a  risk  of  ultimately  exhausting  it.  A  bankruptcy  in 
the  reserve  capital  of  nerve-force  entails  untold  ills  to  the  individual. 

The  day  of  reckoning  is  postponed  in  any  given  case  in  direct 
proportion  to  tlie  drafts  made  upon  the  reserve  and  the  amount  of  the 
reserve.  This  may  help  us  to  explain  why  some  escape  it  indefinitely, 
while  others  are  precipitated  into  indescribable  distress  when  life  is 
hardl}'  begun. 

In  case  the  bearing  of  eye-strain  upon  the  problem  of  nervous 
expenditure  is  not  very  clear  to  some  of  my  readers,  I  deem  it  wise  to 
quote  here  some  extracts  from  a  late  brochure  of  mine  upon  this  subject 
{N.  Y.  Medical  Journal,  Feb.  27  and  March  13,  1886). 

*  See  article  by  Dr.  G.  T.  Stevens  in  the  Archives  of  Ophthalmology,  1S87  and  1888. 


FUNCTIONAL   NEKVOUS   DISEASES   AND   EEFLEX   CAUSES.       467 

Speaking  of  hjperopia,  I  say : — 

Fortunately  for  our  nervous  system,  the  normal  eye  takes  pictures  of  surrounding 
objects  without  any  mtiscular  effort  when  the  object  is  more  than  twenty  feet  away;  hence, 
during  the  larger  part  of  each  day  the  normal  eye  is  passive,  and  is  practically  at  rest, 
although  performing  its  functions.  How  different  is  the  condition  of  the  far-sighted  or 
"  hyperopia "  eye,  however,  from  the  normal!  For  this  eye  (sines  it  is  too  short  in  its 
antero-posterior  axis)  all  objects  have  to  be  focused  by  muscular  effort,  irrespective  of 
their  distance  from  the  eye.  Such  an  eye  is  never  passive.  It  has  no  rest  while  the 
body  is  awake.  It  is  always  straining  more  or  less  intensely  to  bring  properly  upon  the 
retina  the  images  of  objects  seen. 

The  "  hyperopic  "  condition  of  the  eye,  or  "  far-sightedness,"  as  it  is  called,  is  a  very 
common  defect.  It  is  especially  frequent  in  persons  of  tubercular  parentage.  It  is  well, 
therefore,  to  suspect  the  existence  of  this  defect  in  children  or  adults  whose  ancestors 
have  died  of  "  consumption." 

Again,  speaking  of  muscular  anomalies,  I  use  the  following  illus- 
tration : — 

A  high-couraged  horse  feels  the  will,  as  well  as  the  support,  of  his  driver  through  the 
reins  by  means  of  the  bit.  Although  his  course  and  rate  of  speed  are  changed  from  time 
to  time  at  the  will  of  the  driver,  the  reins  are  never  slackened.  The  horse  becomes 
acquainted  with  the  desires  of  his  master  by  a  sense  of  increased  or  diminished  tension 
upon  the  reins.  He  is  guided  to  either  side  by  a  difference  in  the  tension  of  the  two, 
although  the  driver  does  not  entirely  relax  his  hold  upon  the  opposing  rein  while  he  uses 
the  guiding  one,  and  the  difference  in  tension  may  be  very  slight. 

So  it  is  with  the  normal  eye.  It  is  both  controlled  and  supported  while  performing 
its  movements  within  the  orbit  by  the  eye-muscles  (which  are  its  reins).  The  brain  is  the 
driver.  At  its  command  the  eye  revolves,  or  remains  stationary  at  any  desired  point. 
The  tension  of  muscles,  opposed  to  any  movement  of  the  eye  required,  is  so  modified  by 
the  brain  as  to  msure  the  requisite  support  to  the  eyeball,  and  to  steady  it  as  it  moves. 
Thus,  a  perfect  equipoise  is  constantly  established  between  opposing  forces,  adjusted  with 
the  nicest  care  to  meet  the  full  requirements  of  the  organ  under  all  possible  circumstances. 
The  normal  eye  does  not  tremble  or  wabble  when  it  moves  or  the  attempt  is  made  to 
hold  it  in  any  fixed  attitude.  It  is  a  piece  of  machinery,  perfect  in  all  its  parts,  reliable 
in  its  movements,  perfectly  controlled  by  its  master. 

The  eye  with  "muscular  insufficiency"  is  like  a  horse  with  an  inexperienced  and 
incompetent  driver:  the  proper  tension  upon  the  reins  is  not  maintained  at  all  times,  as  it 
should  be ;  there  is  no  equilibrium  between  antagonistic  muscles ;  fixed  attitudes  are 
maintained  with  difficulty  for  any  length  of  time ;  the  brain  becomes  more  or  less 
disturbed  by  its  inability  to  properly  control  the  eye-movements,  and  exhausted  by  the 
continual  strain  imposed  upon  it  by  the  efforts  required  to  do  so  even  imperfectly. 

A  point  may  now  be  raised  concerning  which  some  misapprehension 
seems  to  exist  among  medical  men  (judging  from  remarks  which  I 
occasionally  hear  expressed).  I  refer  to  the  relationship  of  actual 
squint  to  nervous  disturbances. 

No  one  can  deny  that  people  frequently  live  for  long  periods  of 
time  in  houses  impregnated  with  sewer-gas  and  in  the  most  malarious 
regions  without  apparently  suffering  in  consequence.     Yet  no  intelligent 


468  LECTURES   ON  NERVOUS   DISEASES. 

Hum  would  attempt  to  prove  to-day  that  sewer-gas  poisoning  and 
malarial  infection  were  delusions  simply  because  some  people  had  escaped 
their  influence. 

The  argument  has  been  advanced  that,  because  some  cross-eyed 
people  have  escaped  epileps}-,  chorea,  insanity,  and  functional  neuroses 
of  the  milder  types,  it  is  erroneous  to  maintain  that  eye-strain  has  any- 
thing to  do  with  these  conditions.  This  is  absurd  upon  its  face.  The 
hint  might,  perhaps,  be  pertinently  dropped  in  this  connection  that 
cross-eyed  people  practicall}'  suffer  but  little  from  their  muscular  error, 
simply  because  they  have  habitual  double  vision,  which  no  effort  on  their 
j)a,rt  can  correct.  These  subjects  learn  very  quickly  to  practically 
discard  one  image  (the  one  seen  by  the  crossed-eye)  and  to  use  one  eye 
only  for  ordinar}^  vision.  In  other  words,  they  never  try  to  blend  the 
images  of  the  two  eyes,  except  in  cei'tain  attitudes  of  the  head,  which 
result  in  a  single  visual  image  without  an  effort  on  the  part  of  the 
patient. 

It  is  only  in  those  cases  where  (in  spite  of  a  muscular  error)  the 
images  of  the  two  eyes  can  be  blended  hy  a  great  effort  that  the  patient 
begins  to  experience  the  deleterious  physical  influences  of  abnormal 
muscular  tension  in  the  orbit. 

If  we  admit  the  proposition  that  ej'e-defects,  or  anomalies  of  the 
ocular  muscles,  ai'e  liable  to  become  causes  of  impaired  nervous  energy 
(because  they  demand  an  excess  of  nervous  expenditure),  we  are  forced 
to  the  conclusion  that  the  earlier  this  source  of  phj^sical  depression  is 
removed  the  better  are  the  prospects  of  the  person  so  relieved  of 
escaping  diseases  which  impaired  nervous  energy  necessarily  tends  to 
hasten  or  develop.  We  are  naturally  led  to  question  if  the  so-called 
"  neuropathic  predisposition  "  is  not  dependent  (in  a  certain  proportion 
of  cases,  to  say  the  least)  upon  "  ej'e-strain."  We  might  possibly  also 
be  led  to  think  that  the  so-called  "  tubercular  tendenc}' "  (which  is 
l)resent,  as  far  as  my  observation  goes,  in  nearly  50  per  cent,  of  all  cases 
of  marked  functional  nervous  disease)  might,  in  some  eases,  be  modified, 
controlled,  or  perhaps  arrested  before  its  physical  results  become 
apparent  by  taking  from  the  life  of  such  subjects  a  load  which  their 
small  reserve  capital  of  nervous  energy  particularly  unfits  them  to 
endure. 

It  is  hard  to  give  up  the  view,  so  universall}'  conceded,  that  a 
predisposition  to  disease  means  a  ''constitutional  taint."  Yet,  in  many 
cases,  we  are  absolutely  unable  to  demonstrate  that  any  evidence  of 
physical  weakness  or  disease  has  appeared  until  sufficient  time  had 
elapsed  from  the  date  of  birth  for  the  deA'elopment  of  a  serious  impair- 
ment of  nervous  energy.  What  has  caused  it?  Has  it  been  deficient 
nourishment,  a  lack  of  maternal  care  or  solicitude   during  childhood, 


FUNCTIONAL   NEKVOUS   DISEASES   AND   KEFLEX   CAUSES.       469 

gross  violutions  of  the  rules  of  hygiene,  or  a  lack  of  prudence  on  the 
part  of  the  individual  when  of  matured  experience?  The  history  of 
case  after  case  answers  "  no  "  to  such  surmises.  These,  then,  are  not  the 
all-important  factors  in  every  case.  Phthisis,  epilepsy,  chorea,  headaches, 
neuralgias,,  hysteria,  dyspepsia,  obstinate  constipation,  nervous  prostra- 
tion, inebriety,  and  many  other  evidences  of  the  neurasthenic  state  are 
markedly  hereditary.  What  is  the  load  (if  any)  which  manj-  sufferers 
of  this  t3'pe  are  carrying  through  life?  Have  they  a  congenital  burden — 
which  is,  perhaps,  too  often  unrecognized  ?  I  leave  these  questions  for 
future  research  to  solve. 

In  this  section  I  will  call  attention  to  a  few  cases  selected  from  my 
own  case-book  where  the  relief  of  ocular  defects  produced  remarkable 
and  unexpected  benefit  after  all  hope  of  recovery  had  practicall}'  been 
abandoned  by  the  patient. 

I  bring  these  cases  prominentl}'  forward  in  the  interest  of  science 
onl3^ ;  because  the  improvement  made  by  f hese  patients  is  attributable 
not  to  drugs,  but  soleh'  to  Nature,  when  a  burden  of  which  she  could 
not  rid  herself  was  taken  awa}'  and  recuperation  became  possible. 

Did  you  ever  see  a  tired  horse  fall  prostrate  under  an  excessive 
burden?     Hoiu  long  ivould  he  remain  «o,  ivere  the  burden  not  removed? 

Now,  it  should  constantly  be  borne  in  mind  that  no  two  cases 
exhibit  identical  manifestations  of  nervous  depression  or  irritation. 
Some  patients  who  are  suffering  from  such  conditions  manifest  the  effects 
in  physical,  others  in  mental  disturbances.  The  heart's  action  ma}-  be 
alone  distui'bed  in  some  cases,  the  stomach  may  give  out  in  others, 
some  may  complain  alone  of  spasmodic  muscular  troubles,  some  may 
notice  its  effects  in  the  eyes,  some  are  rendered  sleepless,  manj'  suff'er 
from  more  or  less  persistent  pains,  a  few  complain  alone  of  skin 
disturbances,  and  so  on  throughout  the  different  parts  of  the  entire 
human  organism. 

We  can  understand  how  these  apparentlj^  discordant  facts  may  be 
reconciled  when  we  recall  the  fact  that  by  means  of  the  brain  and  spinal 
marrow,  and  the  nerves  which  unite  these  centres  to  the  different  parts 
of  the  body,  we  are  enabled  to  see,  hear,  taste,  smell,  appreciate  touch, 
swallow,  breathe,  and  perform  voluntary'  muscular  acts.  It  is  by  means 
of  our  nerves  alone  that  the  heart  l)eats  ;  the  digestive  processes  go  on 
without  our  knowledge  or  control  through  the  same  agencies;  the  blood- 
vessels contract  and  dilate  in  accordance  with  the  demands  for  blood 
telegraphed  to  the  nerve-centre  by  different  organs  and  tissues;  and 
every  process  pertaining  to  life  is  thus  automaticalh'  regulated. 

It  requires  no  medical  knowledge  to  see  at  once  how  a  disturbance 
of  so  complicated  an  electric  mechanism  as  the  nerve-fibres  and  the 
nerve-cells   of  a  living  animal   are   can  upset  all   or   any   one   of  the 


470  LECTURES   ON   NERVOUS   DISEASES. 

individual  functions  enumerated.  Many  of  our  houses  are  furnished 
to-da}'  with  electric  bolls  bj^  means  of  wires  distributed  in  the  wails.  In 
some  houses  we  light  the  gas-jets,  and  even  the  rooms  themselves,  by 
means  of  the  same  subtle  fluid.  When  the  batter^'  becomes  weak,  or  when 
the  wires  are  disarranged  or  broken,  what  ma}'  be  the  results?  Some  of 
the  bells  may  cease  to  ring  when  the  button  is  touched,  while  others 
work  proi)erh'.  Perhai)S  the  electric  light  may  fail  in  some  rooms  and 
burn  with  its  accustomed  brilliancy'  in  others.  The  gas-jets  maj'  not  be 
properly  ignited.  So  it  is  with  the  nervous  apparatus  of  man.  From 
.the  same  cause  one  patient  ma}'  have  nervous  dyspepsia,  another  sleep- 
lessness.  a  third  headache  or  neuralgia,  a  fourth  weakness  of  the  muscles, 
a  fifth  disturbances  of  sensation,  a  sixth  hysteria,  chorea  or  epilepsy-.  It 
is  needless  to  multiply  illustrations. 

The  nervous  system  of  man  has  been  very  aptly  compared  to  a 
mountainous  region  where  an}-  atmospheric  disturbance  calls  forth  a 
"  series  of  echoes  "  at  distant  points.  So  it  is  with  man}-  of  the  so-called 
"functional  diseases."  They  may  be  simply  the  manifestations  of  a 
disturbance  of  the  nervous  system,  entailed  by  causes  which  have  been 
overlooked  or  imperfectly  relieved. 

Before  I  leave  this  subject  it  is  but  proper  to  say  that  a  few  cases 
reported  by  me  in  this  chapter  (while  not  a  large  number  in  the  aggre- 
gate) were,  without  exception,  well-marked  cases  of  typical  and  intractable 
neuroses.  The  improvement  noted  in  each  case  after  well-directed 
treatment  of  the  eyes  or  the  eye-muscles  tends  to  cast  a  doubt  upon  the 
existence  of  any  organic  disease.  No  other  causes  of  reflex  nervous 
disturbances  outside  of  the  eyes  were  detected  after  a  careful  search  in 
any  of  these  cases;  otherwise  it  would  have  been  my  manifest  duty  to 
relieve  all  that  wei'e  found  in  my  efforts  to  benefit  the  symptoms 
manifested  by  each  patient. 

It  is  not  to  be  expected,  nor  do  I  anticipate,  that  views  so  radically 
opposed  to  the  ordinary  methods  of  treatment  by  medication,  now  gen- 
erally advocated  for  functional  nervous  diseases,  will  be  accepted  at  once 
by  the  profession  at  large,  even  if  correct  and  satisfactorily  demonstrated. 
No  great  advance  in  science  has  ever  been  made  until  time  has  tem|)ered 
prejudice  and  modified  the  prevailing  tendencies  of  thought. 

Of  late  years  we,  as  a  profession,  have  had  our  attention  drawn, 
however,  more  seriously  than  ever  before  to  the  clinical  importance  and 
the  necessity  of  detection  of  remote  sources  of  irritation  to  the  nervous 
centres.  We  have  already  learned  that  the  ovaries,  the  womb,  the  pre- 
puce, the  urethra,  the  rectum,  the  alimentary  canal,  etc.,  can,  in  some 
instances,  induce  serious  nervous  conditions  which  closely  simulate  the 
evidences  of  organic  disease.  Complete  paralysis  of  both  legs  has  been 
known  to  be  cured  in  a  child  by  circumcision.     The  operation  devised 


FUNCTIONAL   NERVOUS   DISEASES   AND   REFLEX   CAUSES.        471 

by  Battey  for  the  removal  of  the  ovaries  in  subjects  attacked  with 
h3'stero-epilei)sy  is  to-day  sustained  by  the  profession,  and  often 
performed  with  the  view  of  removing  a  merely  suppositious  source  of 
reflex  disturbance.  This  supposition,  in  many  cases,  is  based,  unfortu- 
nately, upon  tests  much  less  scientific  and  therefore  less  reliable  than  the 
tests  employed  to  detect  anomalies  of  the  visual  apparatus.  It  is  safe  to 
question,  therefore,  if  the  source  of  reflex  irritation  in  many  patients  of 
this  class  has  been  carefully  sought  for,  and  if  it  does  not  lie  more  in  the 
eyes  than  in  healthy  ovaries,*  which  are  not  infrequently  sacritieed. 
Personally,  I  should  not  feel  justified  in  taking  so  serious  a  step  with 
any  patient  until  every  other  possible  cause  of  reflex  disturbance  had 
been  carefulh'  sought  for  in  vain. 

There  is  no  doubt  tliat  man}'  physicians  of  prominence  are  devoting 
more  attention  to-day  in  their  practical  office  w^ork  to  the  determination 
of  latent  refractive  errors  in  the  eye  and  disturbances  of  equilibrium  in 
the  eye-muscles  than  was  their  habit  in  years  past. 

This  long-neglected  but  important  element  in  the  "  neuropathic 
tendency  "  (and  perhaps  also  in  the  "  tubercular  predisposition  ")  is  now 
receiving  from  many  sides  the  most  thoughtful  consideration.  Sooner 
or  later,  in  my  opinion,  our  views  of  the  causes  of  functional  nervous 
disease  will  no  longer  be  those  now  advanced  in  most  of  the  works 
devoted  to  that  field.  We  shall  in  time  more  clearly  recognize  the  fact 
that  drugs  do  more  harm  in  functional  neuroses  than  good  wlienever  any 
exciting  cause  of  such  a  morbid  condition  persists  and  can  be  removed; 
just  as  we  to-day  rel}^  in  case  of  a  joint-disease,  more  upon  mechanical 
separation  of  the  surfaces  of  the  inflamed  joint  than  upon  anodynes  to 
relieve  the  pain.  We  shall  learn  to  search  more  carefully  and  intelligently 
for  obscure  causes  of  reflex  disturbances,  and  to  try  the  effect  of  their 
removal  before  we  resort  to  drugs.  Medication  must  eventually,  in  my 
opinion,  become  the  dernier  ressort  of  the  physician,  in  this  jmrticular 
class  of  nervous  diseases,  rather  than  the  haven  of  refuge. 

We  are  now  prepared  to  discuss  some  of  the  various  forms  of 
functional  nervous  disturbances  commonly  encountered  in  medical 
practice. 

The  term  "  disease "  can  hardl}'  be  applied  to  a  condition  whose 
morbid  anatomy  is  unknown  (as  is  the  case  with  epilepsy,  chorea, 
hysteria,  hystero-epilepsy,  migraine,  and  certain  forms  of  peripheral 
paralysis,  and  neuralgia).  These  abnormal  states  are,  properly  speaking, 
but  symptoms,  the  exciting  cause  of  which  maj-  often  be  involved  in 
obscurity,  and  the  removal  of  which  must,  of  necessity,  form  a  very 
important  factor  in  the  treatment. 

*  Cysts  in  the  ovary  are  seldom,  if  ever,  wanting;  hence,  they  can  scarcely  be  pro- 
nounced (when  small)  an  evidence  of  disease. 


472  LECTURES  ON  NERVOUS  DISEASES. 


EPILEPSY. 

Of  all  the  so-called  ''  functional "  nervous  diseases,  this  condition 
merits  attention  first,  because  it  is  the  most  grave.  It  consists  of 
periodical  convulsive  attacks,  associated,  in  tj'pical  cases,  with  a  loss  of 
consciousness. 

The  paroxysms  may  var}-  in  regard  both  to  their  frequency  and 
severity. 

The  extent  of  the  coma,  the  duration  of  the  fit,  the  parts  con- 
vulsed, the  mental  aberration,  and  the  constitutional  effects  which  follow 
the  attack  vary  also  in  different  subjects.  Among  the  ancients,  this 
condition  was  regarded  with  peculiar  horror,  and  was  attributed  to  the 
"possession  of  a  devil." 

Varieties. — Custom  has  established  a  classification  of  this  con- 
dition into  types,  as  follows  : — 

(1)  The   "grand  mal"   or   typical   attack,  where   consciousness   is 
totally  absent  during  the   convulsive  stage. 

(2)  The  "petit  mal  "  or  mild  attack,  in  which  consciousness  may  be 
wholly  or  partially  retained,  and  the  convulsive  movements  may 
be  slight  or  absent. 

(3)  To   these,  may   be   added    a   condition   known   as   "irregular 

EPILEPSY." 

These  distinctions  are  not  clinically  accurate.  Cases  do  occasionally 
occur  where  consciousness  ma}'  be  wholly  lost,  and  yeX,  the  convulsive 
movements  may  be  partial  rather  than  general.  Again,  general  con- 
vulsions of  a  severe  type  have  been  observed  in  rare  cases  where  con- 
sciousness has  been  perfectlj'^  retained.  I  have  encountered,  moreover, 
a  few  cases  of  petit  mal  where  certain  peculiar  attitudes  of  the  ex- 
tremities and  face  have  taken  the  place  of  convulsive  movements  and 
consciousness  has  been  onh'  imperfectly  lost. 

I  have  frequentl}^  seen  patients  have  an  epileptic  attack  in  my  office 
while  sitting  upon  a  chair  without  falling  from  it.  One  patient  now 
under  my  charge  has  had  numerous  attacks  while  walking  in  the  street, 
which,  as  his  attendant  assures  me,  did  not  demand  an}'  aid  on  his  part 
toward  supporting  the  patient. 

Etiology. — Heredity  plays  an  important  part  in  the  history  of  many 
cases.  A  record  of  epilepsy,  hysteria,  insanity,  chorea,  migraine,  or 
phthisis  is  commonly  found  to  exist  in  some  branches  of  the  ancestral 
line.  Inebriety  may  also  have  been  frequentl}'  observed  on  the  father's 
or  mother's  side. 

Some  adults  are  apt  to  trace  their  first  fit  to  masturbation ;  or 
to  excessive  venery,  some  great  mental  excitement  or  strain,  or  some 
infectious  disease  (prominently  s^-philitic  infection). 


EPILEPSY.  473 

Most  epileptics  also  give  a  history  of  some  severe  injuries  received, 
to  wliicli  they  attribute  (too  often  erroneously)  their  convulsive  attacks. 
Investigation  will  usually  show  that  these  injuries  are  apt,  however,  to 
be  the  result  of  an  attack  rather  than  cause,  or  to  be  a  mere  coincidence. 
Traumatism  may,  unquestionably,  in  rare  cases,  prove  an  exciting  cause 
of  epilepsy,  but  I  believe  the  frequency  of  such  cases  to  be  greatly  over- 
estimated.    The  same  remark  would  apply  to  some  organic  brain-lesion. 

In  the  third  place,  any  condition  which  creates  marked  reflex 
irritation — such,  for  example,  as  eye-defect,  dental  irritation,  phimosis, 
gastric  or  intestinal  disturbances,  cicatrices  involving  nerve-filaments, 
foreign  bodies  or  wax  in  the  ear,  ovarian  irritation,  uterine  or  rectal 
diseases,  the  first  menstruation  or  coitus,  etc. — may,  in  some  subjects, 
induce  epileptic  seizures.  A  large  proportion  of  the  epileptic  attacks 
of  infancy  are  unquestionably  brought  about  by  trivial  reflex  causes.*  In 
adults,  however,  the  reflex  causes  enumerated  (with  the  exception  of 
"eye-strain"  and  bad  teeth)  are,  in  my  opinion,  less  apt  to  induce  true 
epilepsj^  than  the  profession  generally  suppose. 

It  is  very  uncommon,  in  my  experience,  to  meet  with  male  or  female 
adults  (in  whom  attacks  of  epilepsy  have  commenced  after  the  seventh 
year)  which  fail  to  show  some  abnormality  of  refraction,  or  in  whom  the 
condition  known  as  "  ocular  insuflflciency  "  is  not  found  to  exist  to  a 
marked  degree. 

I  have  one  patient  under  my  care  at  present  who,  for  j^ears,  had 
alwa^^s  been  seized  with  an  attack  on  suddenly  going  from  the  light  into 
darkness.  Another  (who,  happil}^,  has  apparently  about  recovered  after 
partial  tenotomies  performed  upon  the  eye-muscles)  had  the  first  two 
attacks  when  exposed  to  the  dazzling  reflectien  of  the  bright  sun  upon 
a  rough  sheet  of  water,  and  was  rescued  from  drowning  twice  in  conse- 
quence. A  third  patient  of  mine,  who  had  several  attacks  daily  when 
on  land,  would,  strange  as  it  seems,  skip  many  weeks  without  a  fit  when 
on  shipboard,  where  his  efforts  to  accommodate  vision  for  near  objects 
were  infrequent.     He  had  very  serious  refractive  and  muscular  anomalies. 

Finally,  it  must  be  conceded  that  organic  changes  within  the  brain- 
substance  or  irritative  lesions  of  the  vortex  may,  in  a  certain  proportion 
of  cases,  induce  epileptic  attacks.  A  depressed  fracture  of  the  cranium 
or  an  exostosis,  for  example  ;  a  meningeal  thickening ;  an  abscess  within 
the  skull ;  parasitic  deposits  ;  gummata,  etc.,  have  been  shown  to  have 
induced  attacks  of  this  character. 

We  may  assume  in  cases  of  epilepsy  that,  as  a  rule,  the  condition 
becomes  more  grave  after  the  seventh  3'ear  than  in  early  childhood, 
especially    if  no   well-ascertained    cause   of   reflex   irritation   can   be 

*  Worms,  indigestion,  phimosis,  teething,  etc.,  are  often  accompanied  by  epileptic 
attacks  in  infancy  or  early  childhood. 


474 


LECTURES   ON   NERVOUS   DISEASES. 


discovered.  It  is  impossible  as  j-et  to  express  any  definite  knowledge 
regard iUi^  the  relative  frequency  of  such  causes  to  the  total  number  of 
epile[)tics  encountered, — because  tlie  publisiied  records  of  such  cases  are 
singularly  imperfect  in  reference  to  the  examination  of  the  eye.  The 
following  statistics  (taken  from  Dr.  Stevens'  prize  essa3')  will,  however, 
prove  of  interest  in  this  connection  : — 

Total  number  of  cases  reported 140  \  These  include  all  cases  up  to 

Total  taken  from  the  author's  private  practice,  .       85  j  1882. 

An  analysis  of  100  consecutive  cases  of  typical  epilepsy,  from  number 
above  mentioned,  shows  the  following  refractive  errors  to  have  existed  : — 


Hyperopia  or  Hypeeopic  Astigmatism, 
Myopia  or  Myopic  Astigmatism,     .     . 
Refractive  errors  of  less  than  1  dioptre, 


present  in  59  cases,  or  59  per  cent. 
23        "        23 
"     _18^       "        18 

Total,       100 


The  condition  of  the  eye-muscles -was  not  sufficientl}' well  reported 
in  many  of  these  cases  to  allow  of  percentages  being  given  in  reference 
to  this  important  factor. 

My  owni  examinations  up  to  188T,  of  a  much  smaller  number,  show- 
that  my  private  cases  possess  a  much  larger  percentage  of  hyperopic 
abnormalities  (in  excess  of  1  dioptre),  and  a  smaller  proportion  of 
myopic  defects.  In  fourteen  cases  carefully  observed,  prior  to  1887, 
nine  were  markedly  hyperopic,  four  were  myopic  in  excess  of  one  dioi)tre, 
and  only  one  was  emmetropic.  In  every  case  but  one,  a  marked  condi- 
tion of  esophoria  was  found.  In  five,  hyperphoria  existed  in  addition  to 
esophoria.  In  the  remaining  case,  a  hyperphoria  of  about  ^  degree  was 
all  that  was  detected.  The  following  summary  of  these  cases  may  shed 
possibly  some  additional  light  upon  this  new  field  of  inquiry  : — 

Total  eases,  14.     (All  of  the  severe  tj^pe.) 


FREQUEXCY  OF  THE  AT-  I 
TACKS     (IX     Sl'ITE     OF  ] 

ACTION  OF  BROMIDES)     Refractive 
WHEN  FIRST  SEEN.  Error  t 


examination  of 

THE    EYES. 


Average  of  over  Ave  fits     H.,  7  cases. 

each  day,  1  case. 
Average  of  three  per  day,     Ha.,  4  cases. 

M.,  4  cases. 

Ma..  1  case. 

Em.,  1  case. 


4  cases 

Average  of  two  per  day, 
2  cases. 

Average  of  one  per  week. 
2  cases. 

Average   of   one    per 
month,  3  cases. 

Occasional    attacks,    2 
cases.  I 


Muscular 
Error. 

Esophoria. 

13  cases. 

Hyperphoria, 
5  cases. 

Exophoria, 
0  case. 

Heterophoria. 

14  cases. 

Orthophoria, 
Ocase. 


MENT.\L, 

state 
of  patient. 


Markedly  af- 
fected in  o  cases. 

Slightly  affected 
in  3  cases. 

Unaffected  in 
6  cases. 


REMARKS. 


Total  cases=14 


Total=14  » 


One  of  these  rases 
had  .52  convulsions 
in  8  hours,  after 
stopping  the  use  of 
the  lironiides. — each 
fit  lasting  3  min- 
utes. 

In  all  of  these  cases 
the  frequency  of 
the  fits  was  greatly 
increased  when  "I 
discontinued  the 
use  of  the  bromides. 


Total=14 


*Some  of  these  patients  showed  a  more  than  one  eye-defect;  hence,  the.se  two  columns 
cannot  he  tallied. 

t  The  symbols  u^  ed  in  this  table  are  explained  on  p.  130. 


EPILEPSY.  475 

Morbid  Anatomy. — In  spite  of  tlie  fixct  that  much  has  been  written 
upon  this  subject,  no  primary  changes  of  an  anatomical  character  can  be 
asserted  to  be  patliognomonic  of  epilepsy. 

In  this  view,  I  think  that  most  of  the  later  authorities  stand 
agreed. 

The  view  of  Schroeder  Van  der  Kolk  (1859)  that  the  vessels  of  the 
posterior  half  of  tlie  medulla  (those  atiecting  chiefly  the  roots  of  the 
vagus  and  hypoglossal  nerves  and  the  fourth  A'entricle)  w'ere  imnatu- 
rally  dilated  is  not  now  accepted.  That  of  Kroon  (asymmetry  of  the 
olivary  bodies) ;  of  Solbrig  (constriction  of  the  spinal  canal,  with  second- 
ary- atrophy  of  the  medulla) ;  of  Lelut  (sclerosis  of  Amnion's  horn) ;  of 
Cooper  (compression  of  the  carotid  arteries) ;  of  Landois  (venous  hyper- 
aemia  of  the  brain  and  spinal  cord)  ;  of  Nothnagel  (irritation  of  the 
"convulsive  centre  "  in  the  region  of  the  medulla  and  pons) ;  and  many 
other  equally  fanciful  h3-potheses  have  been  proven  to  be  more  or  less 
fallacious. 

The  exhaustive  paper  of  Hughlings-Jackson  (1873),  in  which  he 
advocates  the  theory  of  "  explosive  discharges  "  of  the  cells  of  the  brain 
in  epileptic  attacks,  is  rather  physiological  than  pathological  in  its  scope. 
If,  as  he  believes,  a  maUnutrition  of  the  brain-cells  exists  as  a  primary 
state  (which  predisposes  to  these  paroxysmal  explosions)  the  importance 
of  the  detection  and  removal  of  its  cause  becomes  the  more  apparent. 
The  paper  referred  to  aids  us  more  in  localizing  an  intra-cranial  lesion 
of  an  irritative  type  than  in  explaining  the  occurrence  of  genuine  epilepsy 
as  we  commonly  encounter  it. 

In  the  light  of  later  researches,  it  is,  in  the  opinion  of  the 
author,  not  necessary  to  discuss  at  length  the  view  of  Lasegue 
(1877)  that  epilepsy  proceeds  from  cranial  asymmetry  or  mal- 
formation. 

Brown-Sequard  has  shown  that  animals  can  be  made  epileptic  by 
injuries  to  the  spinal  cord  and  peripheral  nerves ;  but,  as  some  weeks  are 
required  to  induce  this  result,  these  experiments  seem  to  show  that  some 
secondary  changes  in  the  nerve-tissues  had  probabl}'  developed  as  a 
result  of  the  injury  inflicted. 

Eccheverria  claims  to  have  discovered  serious  changes  in  the 
cervical  sympathetic  ganglia  and  the  sympathetic  fibres  in  connection 
with  epilepsy.  Similar  changes  have  been  observed,  however,  by  Mayer 
and  otiiers  in  connection  with  diseases  of  the  brain  associated  with 
vascular  disturljances. 

Symptoms. — The  general  character  of  a  severe  epileptic  attack  has 
been  partially  described  already  in  a  previous  section  (page  155).  It 
will  simi)lify  description  to  consider  certain  features  of  the  attack 
separatel3\ 


476  LECTURES   ON   NERVOUS   DISEASES. 


GRAND  MAL. 

Premonitory  Symptoms.  —  Most  epileptics  affected  with  "grand 
mal "  have  some  peculiar  sensations  (the  a in-se  )  which  indicate  the 
approach  of  an  attack.  Some  subjects  experience  a  marked  change  in 
temperament  for  a  day  or  two  prior  to  the  fit.  They  become  either 
gloom}',  sullen,  inclined  to  anger,  or,  iii  exceptional  instances,  more 
cheerful  than  usual.  Again,  the  skin  of  the  face  and  neck  may  assume  a 
a  dusky  hue  some  hours  before  the  attack.  In  others,  headache,  cardiac 
palpitation,  pain  in  the  pra^cordium,  a  sense  of  distension  of  the  ab- 
domen, a  diarrhoea,  attacks  of  vomiting,  sensitive  spots  on  the  limbs, 
attacks  of  agraphia,  giddiness,  unnatural  loquacity,  etc.,  have  been 
reported  as  forerunners  of  an  epileptic  fit. 

Aurae  connected  with  the  f^jjecial  senses  are  not  uncommon.  Some 
patients  perceive  an  unnatural  color  (usually  red  or  green  or  blue)  in 
the  field  of  their  vision.  Some  patients  of  this  class  habitually  see 
objects  enlarged  or  diminished  in  size, — an  evidence  of  eye-defect.  Others 
see  a  rising  mist  or  various  unnatural  objects  (as  in  a  dream).  To  smell 
bad  odors,  to  hear  strange  or  unnatural  noises,  to  taste  unexpectedly 
obnoxious  things,  or  to  feel  numbness,  etc.,  are  not  infrequently  a  note 
of  warning  to  epileptics  to  seek  a  recumbent  posture. 

The  muscular  aurae  observed  comprise  an  unexpected  and  un- 
controllable spasmodic  movement  in  some  part  of  the  limbs  or  body, 
a  sudden  activity  in  the  facial  muscles,  a  sudden  tendency  to  rotate  the 
body,  or  to  break  into  a  run  while  walking,  and  a  sudden  stift'ness  or 
immobilit}'^  of  a  part. 

Vaso-mofor  aurse  are  not  uncommonly  observed.  Thej'^  comprise 
spots  of  pallor  or  flushing  upon  different  portions  of  the  skin,  an 
unnatural  heat  or  coldness  in  some  part,  a  tendency  to  sudden  local 
perspiration,  and  flashes  of  heat  or  of  cold  shooting  over  the  whole 
body. 

Psychical  aurae  are  occasionally  exhibited  in  the  form  of  delusions, 
hallucinations,  and  illusions. 

The  Epileptic  Cry. — In  a  certain  proportion  of  cases,  a  peculiar  crv 
precedes  the  fit.  It  may  be  a  shriek,  or  again  it  may  be  scarcely  audible. 
I  have  known  it  to  awaken  all  the  patients  in  a  hospital  ward  from  deep 
slumber.  The  patients  are  usually  unconscious  of  having  uttered  it. 
and  it  is  probably  due  to  a  very  forcible  expiration  through  a  partially 
closed  and  rigid  glottis. 

Indications  of  Alarm. — Some  epileptics  have  a  facial  expression  of 
gi-eat  alarm  just  pi-eceding  the  fit.  This  is  more  common  in  children 
than  in  adults.  In  rai-e  instances,  the  attitude  of  the  hands  and  arms 
express  the  same  mental  state. 


GKAND   MAL.  477 

Actual  Symptoms. — At  the  approach  of  the  fit,  it  is  common  to 
observe  a,  marked  facial  pallor.  Even  in  "  petit  mal  "  this  is  generally 
present.     In  exceptional  cases  the  face  may  appear  congested. 

The  Stage  of  Rigidity.  —  If  the  fit  is  a  severe  one,  the  body 
l)ecomes  at  first  as  rigid  as  a  board.  The  limbs  are  extended, 
the  feet  inverted,  the  fingers  and  toes  are  commonly  flexed,  and 
the  head  is  thrown  back  and  usnally  turned  to  one  side.  The 
whole  body  may  be  twisted  backward  or  laterally.  The  ej'es  are 
fixed  during  the  tonic  stage,  and  the  pupils  are,  as  a  rule,  widely 
dilated.  The  breathing  is  partially  or  totally  arrested.  Sensibility 
is  abolished. 

The  Stage  of  Clonic  Spasms. — After  the  tonic  stage  has  lasted 
for  a  short  time  (about  two  minutes  or  less),  convulsive  movements 
begin,  the  whole  body  being  alternately  thrown  into  violent  contraction 
and  relaxation.  The  face  is  distorted  by  terrible  grimaces  and  assumes 
a  purplish  hue.  The  breathing  gradually  becomes  loudly  stertorous; 
the  saliva  escapes  from  the  mouth  as  froth,  and  is  'often  bloody  from 
wounds  inflicted  b}^  the  teeth  upon  the  tongue.  The  urine,  semen, 
and  ftijces  are  often  passed  involuntarily.  The  clonic  spasms  generally 
subside  b}^  degrees,  growing  less  and  less  violent  until  they  entirely 
cease.  As  the  convulsions  subside  the  face  becomes  less  dusky.  During 
this  stage  the  eyes  may  stand  open  and  seem  to  protrude  from  the 
socket;  but  they  are  generally  turned  upward,  so  that  the' white  of 
the  eye  only  shows  beneath  the  blinking  eyelids.  They  sometimes 
become  intensely  congested,  so  as  to  give  the  e^^e  a  resemblance  to 
mw  beef* 

The  pulse  cannot  be  satisfactorily  observed  in  this  stage  on  account 
of  the  muscular  movements. 

Stage  of  Recovery. ^When  the  convulsive  movements  have  entirely 
ceased,  and  the  breathing  has  resumed  its  normal  character,  the  patient 
lies  limp  and  helpless  for  a  short  time  and  gives  evidence  of  a  desire  to 
sleep.  If  aroused,  he  acts  as  if  dazed  and  stupid  ;  answers  questions 
with  reluctance  or  imperfectly  ;  looks  about  him  in  a  semi-conscious  or 
frightened  way  ;  mutters  to  himself  some  unintelligible  sentences ;  and 
relapses  into  a  lethargic  sleep.  Cases  where  complete  epileptic  coma 
has  lasted  forty-eight  hours  have  been  reported.  As  a  rule,  however,  a 
sleep  of  a  few  minutes  suffices  to  enable  the  patient  to  walk  with  slight 
assistance. 

The  fit  usually  leaves  a  sensation  of  dull  headache  for  several  hours 
and  great  muscular  fatigue. 

*  Serious  difficviltios  may  occasionally  arise  from  this  intense  congestion  after  a  partial 
tenotomy  of  the  eye-museles  has  been  performed.  I  have  had  two  patients  intensify  the 
effect  desired  from  a  graduated  tenotomy  by  a  fit  occurring  soon  after  the  operation. 


478  LECTURES  ON   NERVOUS  DISEASES. 

In  very  severe  fits,  the  teeth,  and  even  the  jaw  itself,  have  been  broken 
by  tlie  violent  muscular  movements,  the  tongue  completely  divided,  the 
clavicle  fractured,  and  muscles  torn  across.  One  of  my  patients  worked 
his  way  through  the  ash-door  of  a  furnace  (12x16  inches)  during  an 
epileptic  fit,  and  the  brick-work  had  to  be  removed  to  extricate  him. 
Fortunately  no  fire  was  in  the  furnace. 

Many  epileptics  fall  very  violently  when  the  fit  comes  on,  because 

of  insufficient  warning.      It  is  very  common,  therefore,  to  encounter 

scars  on  difterent  portions  of  the  body  in  these  subjects.     The  edges  of 

the  tongue  usually  give  more  or  less  evidence  of  previous  attacks  of 

"grand  mal."     They  are  badly  scarred,  or  ragged,  from  imperfect  union 

of  old  wounds. 

PETIT  MAL. 

The  milder  forms  of  epilepsy  may  assume  a  variety  of  types. 
Personally,  I  do  not  regard  any  attack  as  one  of  true  epilepsy  unless 
consciousness  is  more  or  less  completely  lost ;  hence,  I  do  not  usually 
include  among  this  particular  class  those  subjects  who  suddenly  have 
some  of  the  premonitory  symptoms  of  grand  mal,  already  described,  and 
still  retain  a  perfect  knoAvledge  of  their  surroundings. 

Subjects  afflicted  with  petit  mal  often  assume  a  fixed  attitude  without 
any  premonition  of  an  attack,  and  stare  unconsciously  for  a  few  seconds. 
I  once  had  a  patient  who  would  frequently  do  this  at  a  card-table  without 
dropping*  a  card  or  losing  the  run  of  the  game.  He  played  for  very 
heavy  stakes  and  was  usually  a  winner. 

Occasionally,  these  subjects  will  stop  in  the  middle  of  a  sentence, 
grow  pale  or  red,  and  remain  motionless  for  half  a  minute  or  more  with 
the  eyes  staring  into  vacancy.  The}'  will  then  finish  the  sentence  and 
be  unaware  of  the  intermission  which  had  possibly'  alarmed  the  rest  of 
the  company. 

Facial  grimaces  or  slight  twitchings  of  the  muscles  may  occur  in 
more  severe  attacks  of  this  character,  and  the  urine  may  be  voided 
unconsciously. 

Some  attacks  of  this  type  are  exhibited  by  the  patient  walking  about 
in  an  aimless  way,  with  inarticulate  mutter ings,  as  if  in  search  of  some- 
thing. 

Petit  mal  is  usually  associated  with  some  ill-defined  aura,  which 
leads  the  patient  to  suspect  that  he  has  had  an  attack  accompanied  by  a 
temporary'  loss  of  consciousness.  Some  subjects  compare  these  attacks 
to  "a  dream;"  others  feel  dizzy  or  nauseated;  a  few  suffer  an  in- 
describable physical  distress.  I  have  had  several  patients  of  this  class 
who  have  told  me  that  they  "  became  l)lind  "  for  a  moment.  An  uncon- 
trollable dancing  of  the  eyes  (nystagmus)  occurs  during  these  attacks 
iu  one  of  my  patients,  of  which  he  is  conscious. 


IRREGULAR  EPILEPSY.  479 

Momentary  strabismus  is  not  infrequently  observed  in  epileptics. 
It  may  occur  independently  of  a  fit  or  in  conjunction  with  one.* 

IRREGULAR   EPILEPSY. 

Tliese  attacks  are  of  a  peculiar  kind,  which  are  indicatiA^e  of  a 
condition  designated  by  Hughlings-Jackson  as  "  mental  automatism." 
Hammond  classes  them  as  aborted  paroxysms. 

Such  attacks  are  characterized  by  acts  on  the  part  of  the  patient  of 
an  impulsive  and  unnatural  character,  of  which  he  is  unconscious.  The}' 
simulate  in  some  cases  attacks  of  momentary  insanity.  There  are  no 
muscular  twitchings,  as  a  rule.  These  attacks  may  occur  in  subjects 
who  have  never  had  either  grand  mal  or  petit  mal.  They  are  usually  of 
short  duration  (a  few  minutes  only,  as  a  rule).  Acts  of  violence  are  not 
uncommon  in  these  attacks.  Patients  often  wander  without  proper 
preparation  through  crowded  streets,  commit  acts  of  immodesty  or 
indecency,  utter  lewd  expressions,  etc.,  during  these  attacks,  without  a 
knowledge  of  doing  so.  Some  suddenly  find  themselves  standing  or 
sitting  in  unexpected  places  (as  in  a  closet),  or  committing  some  act 
which  they  had  no  will  and  often  no  motive  to  perform.  These  attacks 
may  occur  at  any  time  of  the  day  or  night,  and  cannot  usually  be  traced 
to  any  special  cause.  Kleptomania  and  other  unconscious  acts  of  crime 
may  be  attributed  (in  some  cases)  to  this  particular  form  of  epilepsy. 

Diagnosis. — The  various  types  of  epilepsy  ma}-  be  confounded  with 
comatose  states  and  with  other  convulsive  attacks;  such,  for  example, 
as  those  of  cerebral  congestion;  alcohol-  or  opium-poisoning;  the  con- 
vulsions of  uraemia,  hysteria,  apoplexy,  cerebral  organic  lesions,  and 
feigned  epilepsy.  The  table  on  the  following  page  will  aid  the  reader 
in  the  diagnosis  of  some  of  the  more  important  conditions  mentioned. 

COMPLICATIONS   OF  EPILEPSY. 

Various  forms  of  mental  disturbance  may  develop  in  connection 
with  epilepsy.  I  have  observed  several  eases  where  such  disturbances 
have  assumed  the  condition  of  permanent  insanity  ;  but  the}'^  are,  as  a 
rule,  of  short  duration.  The  condition  described  as  "  irregular  epilepsy  ". 
is  particularly  liable  to  manifest  itself  in  this  way.  It  is  stated  by 
Reynolds  that  one-tenth  of  all  cases  of  epilepsy  develop  epileptic  mania. 
This  proportion  seems  to  me  to  be  somewhat  excessive. 

*  In  this  connection  I  may  remark  that  the  constant  efforts  which  epileptics 
commonly  and  unconsciously  make  to  avoid  being  cross-eyed  is,  in  my  opinion,  one  of 
the  causes  of  their  attacks.  If  they  were  actually  cross-eyed,  they  would  learn  soon  to 
disregard  the  visual  image  of  the  distorted  eye,  and  their  diplopia  would  be  clinically  of 
no  account.  As  it  is,  they  suffer  in  many  cases  from  a  very  high  degree  of  "  latent " 
insufficiency,  which  they  instinctively  endeavor  to  overcome  in  order  to  prevent  diplopia 
This  subject  has  been  discussed  on  a  preceding  page. 


480 


LECTURES   ON  NERVOUS   DISEASES. 


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PEOGNOSIS   OF   EPILEPSY,  481 

Epileptic  mania  may  lead  to  motiveless  and  atrocious  crimes  in 
some  cases,  and  to  acts  of  indecenc}^  and  vulgarity  in  others.  Again, 
illusions  of  the  special  senses,  melancholy,  or  preternatural  buoj^ancy  of 
spirits  may  be  evidences  of  this  complication.  Epileptic  delirium  is 
therefore  not  always  of  a  dangerous  character ;  although  it  is  liable  to 
become  so,  and  deserves  careful  watching. 

When  idiocy  is  associated  with  epilepsy,  the  former  is  generally 
congenital  or  the  result  of  a  prolonged  use  of  bromides. 

Prognosis. — Authorities  ditFer  respecting  the  indications  for  an 
extremly  unfavorable  prognosis  in  epilepsy.  Some  assert  that  extreme 
frequency  of  the  paroxysms  have  a  serious  significance ;  while  others 
claim  that  the  most  intractable  cases  are  those  who  have  attacks  at 
prolonged  intervals. 

It  is  generally  conceded  that  cases  of  long  standing  are  more 
rebellious  to  any  form  of  treatment  than  in  those  where  the  "  epileptic 
habit  "  has  not  been  developed  to  the  same  extent. 

The  criticisms  which  I  would  make,  in  the  light  of  my  preliminar}'' 
remarks  to  this  chapter,  upon  the  two  former  paragraphs  would  be  this  : 
First,  that  it  is  difficult  (in  cases  where  the  attacks  are  very  infrequent) 
to  tell  positively  when  all  causes  of  reflex  irritation  are  removed  without 
waiting  a  long  time ;  secondly,  that  most  cases  of  long-standing  (irre- 
spective of  the  frequency  of  the  attacks)  are  usually  thoroughly  bro- 
midized  before  reflex  causes  are  searched  for  in  a  scientific  way,  and  are 
suffering  as  much  from  the  deleterious  effects  of  drugs  as  from  the 
epileptic  state. 

Although  mental  failure  is  generally  regarded  as  a  sign  of  evil 
import  in  epileptics,  I  have  seen  several  cases  in  private  practice  where 
a  tenotoni}'  of  the  eye-muscles  has  been  followed  by  marked  recover}'  of 
the  intellectual  faculties,  after  all  drugs  have  been  discontinued.  Photo- 
graphs of  several  patients  operated  upon  by  my  friend,  Dr.  Stevens,  in 
the  Willard  Asylum,  during  the  summer  of  1886,  seem  to  prove  quite 
conclusively  that  some  cases  of  even  chronic  insanity  as  well  as  epilepsy 
are  capable  of  rapid  improvement  when  the  deleterious  effects  of  eye- 
strain and  drugs  are  no  longer  borne  by  the  patient. 

One  case  of  insanity  recovered  his  full  mental  fiicultics  in  a  few 
\^eeks  after  I  performed  a  tenotomy  of  his  internal  recti  muscles,  and  he 
has  shown  no  tendency  to  relapses.  An  epileptic,  in  whom  all  convulsive 
attacks  ceased  after  I  performed  the  same  operation  upon  her,  was  very 
deficient  in  intellect  before  that  step  and  is  now  rather  above  the  average 
in  mental  power.  One  of  the  most  remarkable  cases  that  ever  came 
under  m}'  observation  was  that  of  a  combination  of  chorea,  epilepsy,  and 
idiocy  in  a  girl  about  eleven  years  of  age,  who  completely  recovered  her 
health,  strength,  and  mental  faculties  when  a  refractive  error  in  the  eyes 

31 


482  LECTURES     ON     NERVOUS    DISEASES. 

was  corrected  by  glasses,  and  a  serious  combination  of  muscular  defects 
In  the  orbit  was  adjusted  by  tenotomy.  This  case  was  one  tliat  I  saw 
some  three  years  ago,  in  connection  with  tlie  practice  of  Dr.  Stevens. 
At  the  first  examination,  the  child  could  not  walk  without  being  sup- 
ported  on  both  sides,  drooled  constantly,  talked  unintelligibly,  answered 
questions  with  apparently  little  conception  of  their  import,  could  hardly 
sit  unsupported  in  a  chair  on  account  of  chorea,  had  epileptic  seizures 
repeatedly  during  the  day  and  night,  and  presented  a  most  pitiable  and 
apparently  hopeless  aspect.  I  saw  her  again,  about  a  year  after  the 
operations  were  performed,  at  the  request  of  Dr.  Stevens.  I  found  her 
free  from  chorea  and  epilepsy,  able  to  run  and  skip  a  rope  unaided,  rosy- 
cheeked,  and  in  full  possession  of  her  mental  faculties.  Photographs  of 
this  case  have  been  already  published  by  Dr.  Stevens. 

That  a  persistence  of  epileptic  attacks  for  years  does  not  necessarily 
render  recovery  impossible  is  proven  by  the  fact  that  I  have  personally 
had  three  cases  where  convulsive  seizures  have  been  thus  far  arrested  by 
tenotomies  which  I  performed  ujjon  the  eye-muscles.  All  of  these  cases 
had  been  kept  constantly  under  bromides  for  several  years  without 
apparent  benefit  before  they  were  placed  under  my  care.  Over  a  year 
has  now  elapsed  since  two  have  taken  any  drugs  or  have  had  an  epileptic 
fit,  and  the  third  has  passed  several  months  without  an  attack.  Dr. 
Stevens  reports  several  such  cases ;  which  tend  to  prove  that  permanent 
organic  changes  in  the  cells  of  the  cortex  do  not  necessarily  occur  as  a 
result  of  frequent  and  long-continued  epilepsies. 

Finally,  it  may  be  said  that  little  danger  to  life  is  to  be  apprehended 
in  epileptic  seizures.  I  have  never  known  of  a  case  where  death  occurred 
directly  from  the  fit;  although  many  cases  may  have  met  their  death 
indirectly  from  that  cause,  through  sutibcation,  drowning,  etc. 

Treatment. — From  what  I  have  already  said  in  the  preliminary 
remarks  concerning  functional  nervous  diseases,  it  must  l)e  evident  that 
medication  in  these  afi"ections  constitutes  with  me  rather  a  dernier  ressort 
than  a  harbor  of  refuge.  In  this  view,  I  feel  that  I  am,  as  j^et,  quite 
alone  among  neurologists ;  but  I  am  too  sure  of  my  position  to  doubt 
that  in  time  the  views  which  I  here  advocate  will  not  be  without  other 
enthusiastic  followers. 

The  first  step  in  the  treatment  of  epilepsy  (and  the  same  remarks 
hold  good  for  all  functional  nervous  diseases)  is,  in  my  opinion,  to 
ascertain  (by  all  scientific  means  3'et  noted  and  by  careful  observation 
and  record)  if  any  cause  for  reflex  irritation  exists.  While  I  believe 
that  such  a  cause  will  be  found,  in  a  very  large  proportion  of  such  cases, 
in  the  e3'e,  I  would  not  be  construed  as  stating  that  the  examination 
of  this  organ  should  constitute  the  beginning  and  the  end  of  such 
a  search.     The  womb  and  the  ovaries  in  females,  the  genitals  in  the 


TREATMENT   OF   EriLEPSY.  483 

male,  and  the  teeth  and  rectum  in  both  sexes  may  require  a  careful 
examination. 

I  should  be  very  strongly  led  to  suspect  an  eye-defeet  or  an  "insuffi- 
ciency" of  some  of  the  ocular  muscles  in  case  (1)  the  patient  was  a  young 
adult;  (2)  if  he  had  a  tuberculous  ancestry;  or  (3)  if  he  gave  a  history 
of  epilepsy,  hjsteria,  chorea,  or  insanity,  in  some  branches  of  the  ances- 
tral line. 

The  conditions  of  the  visual  apparatus  which  seem  to  predispose  to 
these  conditions  are  peculiarly  liable  "to  run  in  families,"  and  to  be 
transmitted  (as  features  and  mental  traits  are)  from  parents  to  their 
children.  It  will  generally  be  found  that  "sick-headache"  is  another 
"fiimily  ailment"  among  this  type  of  subjects;  in  case  a  heredity  to  the 
severer  forms  of  functional  nervous  disturbance  is  not  clearly  brought 
out  on  a  careful  line  of  examination.  The  close  relationship  which  exists 
between  this  common  and  excruciating  form  of  pain  and  eye-strain  is 
now  too  well  recognized  to  need  further  comment. 

The  next  question  which  I  should  feel  myself  called  upon  to  decide 
in  a  case  of  epilepsy  (provided  the  previous  lines  of  inquir}^  respecting 
reflex  causes  had  been  pi'osecuted  with  due  regard  to  the  details  given 
for  such  examinations  and  had  yielded  negative  results)  would  be  to 
determine  if  traumatic  conditions  did  not  exist,  which  might  account  for 
the  epileptic  seizures. 

The  steps  indicated  for  the  relief  of  such  conditions  would  depend 
entirely  upon  the  nature  and  seat  of  the  injury  received.  Cerebral 
localization  Avould  then  come  into  play,  and  surgical  interference  would  be 
justified  or  contra-indicated  by  the  conclusions  drawn  from  that  source. 

In  the  third  place,  it  is  always  best  to  examine  with  care  in  any  case 
for  the  symptoms  of  organic  changes  of  a  local  character  either  in  the 
brain  or  its  coverings.  The  hints  furnished  in  Section  II  of  this  worlc 
can  be  reviewed  with  advantage  in  this  connection. 

Finally,  if  all  of  these  lines  of  investigation  give  us  negative  results, 
medication  must,  of  necessity,  come  to  our  aid, — as  an  empirical  and 
most  unsatisfactory  way  to  an  inciuiring  mind  of  controlling  or  modify- 
ing symptoms  which  we  are  unable  to  explain,  and  upon  the  cause  of 
which  pathologists  have  shed  but  little  if  any  light. 

A  few  illustrative  cases  may  be  cited  in  this  connection  with  possible 
advantage  to  the  reader : — 

Case  I.  Chronic  Epilejysy. — Male,  aged  forty-three,  merchant.  Began  to  have  severe 
epileptic  fits  when  seventeen  years  of  age.  Had  masturbated  when  a  boy,  and  had  been 
addicted  in  later  years  to  excessive  venery. 

Family  History. — One  brother  is  a  confirmed  dipsomaniac;  the  father  died  of  ])aral- 
vsis  ;  one  sister  is  a  victim  to  sick -headaches ;  no  phthisis  has  existed  in  the  family,  so  far 
as  could  be  ascertained. 


484  LECTURES   ON   NERVOUS   DISEASES. 

The  epileptic  seizures  of  this  patient  varied  in  frequency  from  two  or  three  a  week  to 
one  in  three  months.  He  came  under  my  care  in  1871  (when  twenty-eight  years  old), 
and  was  treated  by  me  for  many  years  with  enormous  doses  of  the  bromides  of  potassium 
and  sodium.  These  salts  reduced  the  attacks  to  about  four  a  year.  Stopping  the  bro- 
mides invariably  increased  the  frequency  of  the  attacks. 

Eye- defects* — In  January,  1886,  his  eyes  were  examined  after  his  return  from  an 
extended  residence  in  the  South.  He  showed  under  atropine  a  latent  hyperojna  of  2.50  D., 
and  also  a  manifest  esophoria  of  4°.  Subsequently  several  degrees  of  "  latent  "  esophoria 
also  manifested  itself. 

Partial  tenotomies  were  performed  upon  both  interni,  and  hyperopia  glasses  (+  1.50  D.) 
■were  given  him.  Since  the  first  operation  (January,  1886)  he  has  taken  no  bromides  and 
has  not  had  a  convulsion.  He  has  twice  been  "  at  death's  door  "  with  fevers,  but  he  has 
shown  at  no  time  any  epileptic  tendencies. 

Case  II.  Chronic  Epilepsy. — Female,  aged  twenty,  unmarried. 

Family  History. — The  father  died  of  apoplexy.  No  hereditary  tendency  to  nervous 
disease  or  phthisis  could  be  discovered 

The  epileptic  seizures  had  existed  for  five  years  and  developed  after  an  excessive  use 
of  the  eyes  in  sewing  upon  a  black  material.  Menstruation  was  regular.  The  epileptic 
fits  were,  however,  more  frequent  during  the  week  prior  to  and  following  the  menstrual 
epoch.  Under  large  doses  of  bromides  and  ergot  she  had  once  in  her  history  passed  six 
weeks  without  an  attack ;  but  she  averaged,  when  I  first  saw  her,  about  six  attacks  each 
month.  An  epileptic  attack  could  usually  be  induced  hj  fixing  the  eyes  for  a  few  minutes 
intently  upon  some  near  object.  She  had  at  one  time  as  high  as  thirty  severe  fits  in  twenty- 
■fc;ir  hours.  When  the  bromides  were  withdrawn  from  this  patient,  the  fits  increased  to 
f/jveral  each  day  (often  as  high  as  ten  severe  seizures).  She  had  for  years  suffered  from 
obstinate  constipation  and  pain  during  her  menses. 

Eye-defects. — This  patient  was  found  to  be  absolutely  emmetropic  both  before  and  after 
the  use  of  atropine.  She  showed,  however,  an  esophoria  of  5°  and  a  very  low  power  of 
abduction.     Subsequently,  a  large  amount  of  latent  esophoria  developed. 

Several  partial  tenotomies  were  performed  upon  the  interni  of  this  patient  during  an 
interval  of  some  four  months  until  all  latent  esophoria  was  apparently  overcome.  After 
the  first  operation,  the  lacrymal  secretion,  which  was  singularly  defective,  became  normal, 
her  mental  despondency  disappeared,  and  her  attacks  rapidly  diminished  in  frequency. 
Since  June  10,  1886,  she  has  had  no  fits  to  my  knowledge,  nor  to  that  of  her  physician  so 
far  as  I  can  ascertain.  The  case  was  lost  sight  of  by  both  of  us  some  months  ago,  much 
to  my  regret.  When  I  last  tested  her  eyes,  she  showed  no  defect  and  was  apparently  in 
perfect  health.     She  had  passed  several  menstrual  epochs  without  any  epileptic  seizures. 

In  this  case  I  would  call  attention  (1)  to  the  fact  that  emmetropia 
existed ;  (2)  to  the  fact  that  the  ej'e  was  the  apparent  exciting  canse  of 
her  attacks;  (3)  to  the  fact  that  epileptic  seizures  could  be  induced  by 
excessive  use  of  the  internal  muscles  of  the  eye;  and  (4)  that  the 
esophoria  was  "  latent "  to  a  very  marked  degree. 

In  addition  to  these  points  of  interest,  another  fact  is  worth}'  of 
passing  remark,  viz..  that  the  relief  of  the  "eye-strain"  was  followed  in 
this  case  hy  a  total  disappearance   of  the  habitual  constipation  that 

*For  the  meaning  of  terms  employed  in  connection  with  must-uhir  anomalies  of  the 
orbit,  the  reader  is  referred  to  page  143, 


TKEATMENT   OF   EPILEPSY.  485 

previously  had  existed,  and  that  menstruation  ceased  to  be  accompanied 
b}  pain  up  to  my  last  notes  on  the  case.  This  experience,  although 
apparently  a  coincidence,  is  not  by  any  means  infrequent  with  female 
patients,  in  my  practice,  after  a  partial  tenotomy'  of  an  eye-muscle  for 
the  relief  of  an  abnormal  tension  within  the  orbit.  It  is  probably  to  be 
attributed  to  the  fact  that  the  nerve-power  of  the  patient  improves 
rapidly  after  the  excessive  expenditure  of  nerve-force  demanded  by 
abnormal  eye-tension  is  arrested,  thus  allowing  of  an  improvement  in  the 
functions  of  the  other  viscera.  The  introductory  remarks  of  this  chapter 
will,  I  trust,  make  this  explanation  clear  to  my  readers  and  bring  this 
statement  more  into  apparent  harmony  with  physiological  laws. 

Case  III.  Chronic  Epilepsy. — Male,  unmarried,  aged  twenty  years. 

Family  History. — No  consumption  among  the  ancestors  or  immediate  family.  Several 
members  of  the  family  suffer  from  headaches. 

Eye-defects. — Hyperopia  astigmatism  (0.75  Dc.  and  0.50  Dc),  esophoria  (manifest)  of 
6°,  and  latent  hyperphoria  of  a  very  high  degree.  The  latter  has  proved  very  persistent, 
and  has  only  lately  been  satisfactorily  corrected.  The  progress  of  the  case  has  also 
demonstrated  that  a  high  degree  of  latent  esophoria  had  to  be  corrected  in  excess  of  what 
he  at  first  manifested. 

This  patient  was  a  victim  to  the  severest  type  of  chronic  epilepsy.  His  attacks  were 
extremely  frequent  and  severe.  Going  from  light  into  darlcness  would  invariably  cause 
an  attack  and  a  total  loss  of  consciousness.  I  personally  attended  him,  in  connection  with 
Dr.  G.  W.  Leonard,  of  New  York,  when  he  had  fifty-two  epileptic  seizures  in  eight  hours, 
each  fit.lasting  exactly  three  minutes.  All  medicinal  treatment  had  proved  inoperative. 
His  attacks  began  while  he  was  at  school  as  a  child,  and  were  preceded  by  a  difficulty  for 
months  of  keeping  his  place  on  a  page  while  reading.  He  used  to  hold  his  finger  on  the 
line  to  aid  liim  in  reading. 

His  improvement,  after  repeated  tenotomies  upon  both  interni  and  the  left  superior 
rectus,  has  been  most  remarkable.  His  attacks  have  been  decreased  over  75  per  cent. 
He  is  still  under  observation,  with  a  prospect  of  still  greater  improvement,  if  not  of  a 
permanent  cure.  He  has  taken  no  bromides  or  medicine  of  any  kind  save  an  occasional 
diuretic  (tincture  of  iron)  for  sluggish  kidneys. 

The  photographs  of  this  patient,  which  I  now  possess,  hardly  show 
the  happy  change  which  has  occurred  since  the  last  was  taken,  in  spite 
of  the  complete  cessation  of  the  bromides  for  about  eighteen  months.  . 

In  place  of  the  dull,  apathetic,  and  sluggish  features  which  indicate 
the  impaired  mental  state  of  the  patient  from  the  bromides,  in  the  second 
photograph  an  animated  expression  and  a  siiortening  of  the  face  can  be 
seen,  which  are  much  more  apparent  to-day  even  than  when  it  was  taken. 
The  change  in  his  general  health  and  ph^'sical  strength  has  been  even 
more  marked  than  his  facial  changes. 

Case  IV.  Chronic  Epilepsy. — Female,  unmarried,  aged  nineteen  years. 
Family  History. — Paternal  grandmother  died  of  phthisis.     The  mother  has  migraine. 
The  brother  has  migraine.     A  paternal  aunt  was  insane. 

Eye-defects. — A  high  degree  of  myopia  (3.75  D.)  and  myopic  astigmatism  (1.50  D.). 


486  LECTURES   ON   NERVOUS   DISEASES. 

Esophoria  (manifest)  of  9°.  A  high  degree  of  latent  hyperphoria  was  also  discovered 
later. 

Prior  to  my  first  examination  this  young  lady  was  considered  a  hopeless  epileptic. 
She  had  been  for  years  under  the  care  of  several  of  our  most  noted  neurologists  and  oculists. 
After  a  partial  relief  of  her  abnormal  eye-tension  by  tenotomies,  she  went  over  seven 
months  without  an  attack,  and  regained  her  mental  faculties,  which  had  been  somewhat 
impaired  by  bromides.  Within  the  past  four  months  she  has  had  six  attacks  of  epilepsy, 
two  of  which  followed  fright,  one  an  imprudence  in  eating  salads  very  late  and  immedi- 
ately before  going  to  bed,  and  the  fourth  after  the  e.xcitement  attending  a  departure  for  a 
pleasure  excursion.  She  has  lately  manifested  a  latent  muscular  defect  which  I  have  yet 
to  overcome.  From  a  letter  addressed  me  by  her  father  not  long  since  I  quote  the  follow- 
ing paragraphs; — 

"Nothing  but  an  inability  on  my  part  to  pay  for  your  services  would  persuade  me  to 
remove  my  daughter  from  your  care,  and  if  I  could  not  pay  I  would  ask  you  for  charity 
to  keep  her. 

"Her  whole  being  has  been  altered,  and  her  physical  condition  is  better  than  for 
eight  years." 

The  photographs  of  this  patient  show  a  \ery  marked  alteration  in 
her  physical  and  mental  states,  as  a  result  of  the  relief  of  the  muscular 
errors  detected  in  the  orbits.  She  is  now  allowed  to  enjoy  privileges 
which  were  considered  impracticable  prior  to  this  treatment,  such  as  an 
unrestricted  diet,  horseback  exercise,  visits  to  the  city  unaccompanied, 
attendance  at  social  gatherings,  etc. 

As  this  case  is  well  known  to  several  prominent  medical  men  of  New 
York  City,  it  may  be  proper  for  me  to  state  that  since  October  10,  1886 
(some  nineteen  months),  this  patient  has  had  but  eight  epileptic  seizures. 
Prior  to  that  date  my  records  go  to  show  tliat,  even  when  under  bro- 
mides, from  one  to  six  fits  a  day  often  occurred,  and  that  the  nocturnal 
attacks  (which  were  ver}'  frequent)  were  not  ahvays  noted.  It  is  safe, 
therefore,  to  say  that,  had  she  received  no  medicinal  treatment  or  correc- 
tion of  her  eye-defects  during  the  past  nineteen  months,  the  total  number 
of  seizures  would  probably  have  been  more  than  a  hundred  times  this 
number.  She  had  been  known  to  have  as  high  as  seventeen  epileptic 
seizures  during  one  night.  Her  attendant  has  assured  me  that  since  my 
treatment  was  commenced  all  nocturnal  attacks  have  ceased. 

The  point  maybe  raised  that  a  report  of  any  epileptic  case,  until 
the  full  limit  of  three  years  has  been  passed  Avithout  an  attack  and  with- 
out the  employment  of  any  medicine  which  would  control  the  epileptic 
tendency,  must  be  considered  as  somewhat  premature.  In  reply,  I  would 
say  that  the  cases  I  have  brought  forward  are  not  represented  as  cases 
of  radical  cure.  They  ai-e  adduced  simpl}-  as  a  clinical  evidence  that  the 
frequency  of  such  attacks  has  been  greatly  modified,  and  in  two  instances 
completely  controlled  for  long  periods  of  time,  without  the  aid  of  drugs. 
On  the  other  hand,  there  are  now  to  my  knowledge  several  cases  of 
chronic  epilepsy  similarly  treated  that  might  be  brought  forward  (did  I 


TREATMENT   OF   EPILEPSY.  487 

deem  it  necessary  to  quote  from  the  experience  of  another)  which  have 
fulfilled  all  the  requirements  which  would  justify  the  belief  in  a  radical 
cure  of  chronic  epilepsy.  One  of  these  patients  has  passed  over  seven 
years  without  a  lit,  and  several  have  exceeded  the  three-year  limit. 

We  all  admit,  I  think,  that  epilepsy  is  certainly  the  gravest  of  all 
the  functional  nervous  maladies,  and  that  it  is,  as  a  rule,  incurable  b}' 
drugs;  hence,  as  I  have  remarked  in  a  previous  discussion  concerning 
this  subject, "  one  radical  cure  of  epilepsy  without  the  aid  of  drugs  offsets 
a  thousand  failures  as  a  scientific  proof  of  a  discovery." 

It  is  impossible  for  any  one  not  familiar  with  the  difficulties  encoun- 
tered in  the  treatment  of  these  subjects  (alread}^  discussed)  to  appreciate 
the  fact  that,  in  some  cases  of  epileps}^,  e^^e-defects  may  exist  which  can 
not  be  thoroughl}^  rectified;  and  that,  even  in  favorable  cases,  time  and 
patience  are  important  factors  in  the  treatment. 

Epileptics  usually  present,  in  my  experience,  in  addition  to  errors 
of  refraction,  anomalies  in  both  the  lateral  and  vertical  movements  of  the 
e^'es  ;  and  in  some  cases  the  oblique  movements  are  probably  at  fault. 
Moreover,  experience  with  these  subjects  demonstrates  clearly  to  m}' 
mind  that  the  muscular  anomalies  which  exist  are  generally  "  latent "  to 
a  marked  degree. 

It  should  be  remembered  also  that  a  victim  to  chronic  epilepsy  who 
is  rendered  by  any  treatment  as  free  from  attacks  tvithout  the  bromides 
as  he  was  when  under  their  deleterious  influence  has  been  very  markedly 
benefited;  again,  that  if  a  marked  diminution  of  the  attacks  has  been 
effected,  the  patient  has  double  cause  for  gratitude;  finally,  that  if  the 
attacks  are  arrested  in  toto  without  drugs,  it  is  to-day  one  of  the  most 
remarkable  facts  recorded  in  medical  literature. 

There  is  a  point  where  opposition  to  carefully  made  clinical  statistics 
respecting  new  views  ceases  to  be  conservatism.  True  conservatism  is 
the  brake  upon  the  engine  of  progress.  It  is  to  be  used  in  checking  its 
speed  when  going  too  fast,  but  not  in  prcA^enting  its  advance,  even  if 
the  country  is  an  unexplored  field.  Too  often  in  .medicine  the  term 
conservatism  has  become  a  favorite  synonym  for  bigotry  and  intolerance. 

My  own  personal  observations  of  epileptic  subjects,  since  my  atten- 
tion was  first  drawn  to  the  importance  of  a  systematic  examination  of  the 
eyes  and  the  eye-muscles  in  these  cases,  are  not  sufliciently  extensive 
perhaps  to  warrant  any  general  deductions  respecting  the  percentage  of 
such  errors  which  would  be  accepted  as  conclusive;  and  those  of  Dr. 
Stevens  upon  a  larger  number  of  cases  might  also  be  regarded  as  some- 
what insuflicient.  As  yet,  no  scientific  records  of  the  examinations  of 
epileptics  in  respect  to  abnormalities  of  the  ocular  muscles  have  been 
systematically  made,  to  my  knowledge,  in  other  quarters.  Ophthalmo- 
scopic tests  have  been  published  and  errors  of  refraction  have  been 


488  LECTURES   ON  NERVOUS  DISEASES. 

repeatedly  noted,  but  the  tests  to  determine  the  existence  of  esophoria, 
exophoria,  and  hyperphoria  at  twenty  feet  (and  also  at  fourteen  inches 
if  niodilied  by  acconiuiodative  efforts  on  the  part  of  the  patient)  have 
yet  to  be  made  on  a  large  number  of  cases  by  competent  experts  before 
this  matter  can  be  spoken  of  in  an  authoritative  manner.  I  can  only  say, 
in  this  connection,  that  I  have  yet  to  meet  a  case  of  epilepsy  in  my 
private  practice  (which  was  not  clearly  the  result  of  traumatism  or 
syphilis)  that  did  not  exhibit  more  or  less  muscular  error  connected  with 
the  eye  after  the  refractive  error  (if  such  existed)  was  corrected  with  the 
proper  glass.  It  is  but  natural,  therefore,  to  expect  that  further  records 
of  epileptic  cases  which  will  doubtless  appear  hereafter  from  time  to  time 
shall  give  satisfactory  evidence  of  care  and  skill  in  these  important 
examinations. 

The  opposite  page  shows  the  results  of  an  eye-examination  upon 
sixteen  consecutive  cases  of  epilepsy  which  came  under  my  care  during 
the  early  part  of  the  past  year  in  my  private  practice.  It  also  has  a 
bearing  upon  some  other  points  relating  to  epilepsy  which  have  been 
discussed  in  preceding  pages. 

It  will  be  perceived  that  most  of  these  cases  are  of  several  years' 
duration, — enough  to  be  considered  chronic.  In  only  two  of  these  cases 
was  the  eye  emmetropic.  All  but  one  (a  syphilitic  case)  showed  a 
departure  from  the  physiological  state  of  equilibrium  of  the  eye-muscles. 
Several  had  impairment  of  intellect.  In  most  of  the  cases,  the  epileptic 
seizures  were  very  severe  and  of  frequent  occurrence.  All  but  two  had 
been  kept  under  the  bromides  for  long  periods  of  time. 

After  deducting  from  this  list  those  cases  which  either  refused  to 
have  tenotonw  performed,  or  who  failed  from  other  reasons  to  put 
themselves  under  treatment,  eight  remain  that  have  been  operated  upon 
with  the  object  of  correcting  some  existing  muscular  error.  Of  these  eight, 
thi'ee  have  been  thus  far  very  markedly  relieved  of  epileptic  seizures  by 
partial  tenotomies  of  eye-muscles  ;  and  five  are  still  imder  observation. 
No  medicines  have  been  administered  to  any  of  these  eight  cases  to  aid 
in  controlling  the  epileptic  attacks  since  they  have  been  under  my  care. 
Of  the  five  that  are  still  under  observation,  one  has  granular  kidneys  as 
a  complication  ;  and  the  remaining  four  have  still  some  muscular  errors 
in  the  orbit  that  have  not  been  perfectly  corrected  up  to  the  time  of 
writing.  One  of  the  four  has  had  epilepsy  over  twenty  years,  during 
most  of  which  time  she  has  constantly  taken  large  doses  of  bromides  of 
potash,  soda,  and  ammonium. 

The  three  cases  which  are  to-day  apparently  relieved  of  attacks 
were  all  of  the  chronic  type.  All  had  taken  enormous  doses  of  the 
bromides,  and  had  reluctantly  been  forced  to  abandon  them,  either  at 
my  request  or  when  they  ceased  to  be  eflScacious  in  controlling  the  attacks. 


TREATMENT   OF   EPILEPSY. 


489 


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490  LECTURES   ON   NERVOUS   DISEASES. 

One  had  had  epileptic  seizures  for  nearly  thirty  years,  one  for  six  j'ears, 
and  one  for  live  years  prior  to  the  operation. 

Finally,  the  cases  reported  by  Dr.  Bruljaker  of  recoveries  from 
epilepsy  after  the  removal  of  all  sources  of  dental  irritation^  and  of 
many  others  which  show  that  relief  has  followed  the  cessation  oi  ovarian 
irritation,  should  not  be  allowed  to  pass  without  notice. 

Such  cases  as  these  have  a  \exy  important  bearing  upon  the  question 
which  is  now  being  most  earnesth'  investigated  by  some  of  the  leading 
minds  in  the  profession,  viz.,  whether  the  present  methods  of  medicinal 
treatment  of  epilepsy  and  its  allied  disorders  of  the  nervous  sj^stem  are 
not  destined  to  be  superseded  by  more  rational  and  scientific  methods  of 
research  for  the  underlying  causes  of  their  imperfectly  solved  problems. 

In  the  preceding  table,  it  will  be  perceived  that  the  degrees  of 
insufficiency  which  existed  in  each  patient  is  noted.  It  vaQ.y  be  well  to 
state,  in  this  connection,  that  the  highest  degree  of  error  detected  during 
my  observations  of  each  case  is  noted  (rather  than  the  lowest),  because 
this  probably  indicates  the  closest  approximation  to  the  actual  state  of 
the  patient  which  we  can  scientifically  record.  Probably  the  "  latent  " 
insufficiency  vastly  exceeded  in  each  case  the  amount  actually  noted  (see 
p.  456).  In  one  of  Tay  cases  (now  apparently  cured)  one  degree  of  eso- 
phoria  was  all  that  was  detected  on  the  first  examination ;  yet,  in  spite 
of  this  fact,  a  very  free  but  incomplete  division  of  both  interni  was 
required  to  establish  the  phj'siological  equilibrium.  The  attacks  of 
epileps}'  then  ceased,  and  have  not  returned,  to  my  knowledge,  for  over 
thirteen  months. 

Finally,  it  may  be  added,  in  justice  to  the  views  here  advanced,  that 
it  is  not  impossible  that  in  some  of  these  apparently  successful  cases 
a  latent  insufficiency  may  still  be  lurking,  which  the  patient  may  be  able 
to  overcome  for  a  longer  or  shorter  period  of  time  without  producing 
any  abnormal  nervous  manifestations.  Should  such  a  recurrence  of 
ocular  tension  ever  manifest  itself,  it  ought  to  be  corrected  b}'  a  repe- 
tition of  tenotomy,  even  if  the  epileptic  seizures  should  not  reappear  or 
the  patient  apparentl}^  sufljer  from  its  presence.  One  such  case  occurred 
under  the  observation  of  Dr.  Stevens,  where  epileptic  seizures  were 
arrested  for  several  months  by  partial  tenotomies  in  an  apparently 
hopeless  subject.  A  return  of  the  attacks  led  the  patient  to  again  seek 
his  advice,  and  it  was  found  that  a  high  degree  of  latent  insufficiency 
had  manifested  itself.  This  patient  refused,  under  the  advice  of  friends, 
to  continue  the  treatment  (which  had  produced  such  marvellous  results 
but  a  few  months  before),  and  he  returned  to  bromides.  This  case  has 
been  used  b}-  an  opponent  of  these  views  as  an  evidence  of  the  lack  of 
permanency  of  the  results  obtained.  The  injustice  of  such  a  conclusion 
must  be  obvious  to  anv  intelligent  reader. 


TREATMENT   OF   EPILEPSY.  491 

Clinical  facts  go  to  prove  conclusively  that  in  almost  all  epileptic  and 
choreic  subjects  the  manifest  insufflcienc}'  is  much  less  than  that  which 
actually  exists.  It  is  only  after  patient  waiting,  in  some  cases,  that  we 
find  we  have  more  to  deal  with  than  the  patient  at  first  disclosed. 
Whenever  we  find  it,  it  should  be  rectilied  by  proper  methods  and  at  the 
proper  time.  It  should  be  anticipated  and  persistentl}^  looked  for,  over  a 
period  of  many  months.  If  it  fails  to  develop  within  a  year,  we  may  be 
hopeful  that  we  have  overcome  all  that  originally  existed.  If  it  develops, 
we  have  simply  noted  a  condition  that  it  was  reasonable  to  expect,  and 
the  necessity  for  further  operative  procedures  is  clearly  indicated. 

In  one  of  my  successful  cases  no  latent  insufliciency  has  thus  far 
shown  itself,  although  over  two  years  have  elapsed  since  the  last  opera- 
tion. In  another  I  have  not  had  an  opportunity  of  examining  the  patient 
for  some  months.  In  tlie  third,  a  slight  hyperphoria  remains,  which  the 
patient  now  tolerates,  but  whicli  may  require  correction  at  a  later  date. 

Diet  Treatment. — Mau}-  eases  of  epilepsy  are  materially  benefited 
by  a  restricted  diet.  Perhaps  the  one  which  has  given  the  best  results 
consists  in  depriving  the  patient  of  meat-foods  of  every  kind  and 
description.  Even  soups  are  prohibited.  Eggs  and  cheese  are  strictly 
forbidden. 

The  principle  involved  in  this  diet  is  the  withdrawal  of  nitrogen,  as 
far  as  it  is  practicable  to  do  so,  from  the  patient. 

Milk  is  allowed,  as  are  also  its  various  preparations,  such  as  butter- 
milk, skim-milk,  koumiss,  etc.  Vegetables  of  every  kind,  bread,  oatmeal, 
cracked  wheat,  ripe  fruit  of  all  kinds  in  moderation,  and  other  non- 
nitrogenous  articles  of  food  constitute  (with  milk)  the  best  means  of 
nourishing  these  patients. 

Medicinal  Treatment  of  Epilepsy. — No  work  would  be  complete 
without  some  refei'ence  to  the  methods  of  treatment  now  generally 
adopted  for  the  purpose  of  holding  these  attacks  in  check,  in  spite  of 
the  fact  thnt  all  are  more  or  less  detrimental  to  health,  and  generally 
unsatisfactory  both  to  the  doctor  and  patient.  Personally,  I  have  never 
traced  up  a  reported  case  of  cure  of  genuine  epilepsy  with  drugs  alone, 
without  finding  that  the  cessation  of  the  drug  has  been  followed  b}^  bad 
results.  The  best  authorities  speak  with  extreme  caution  respecting  the 
permanent  benefits  which  may  be  expected  of  medication. 

In  infantfi  and  children.,  epileptic  seizures  very  frequently  get  well  if 
let  alone — a  fact  that  is  to  be  explained  by  the  susceptibility  of  the  young 
to  reflex  nervous  disturbances,  and  the  multiplicity  of  causes  of  such 
derangements.  This  fact  is  too  often  overlooked  when  the  eflicacy  of 
drugs  in  such  subjects  (affected  with  epilepsy)  is  called  into  question. 

If,  in  spite  of  careful  scrutiny  into  all  the  possible  factors  which 
have  been  mentioned  as  liable  to  cause  epileptic  seizures,  nothing  can  be 


492  LECTUKES   ON  NERVOUS  DISEASES. 

found ;  or,  if  (when  all  that  may  have  been  discovered  have  been  either 
satisfactorily  removed  or  justly  pronounced  incurable)  the  epileptic 
attacks  persist,  nothing,  unfortunately,  remains  for  such  a  patient  but  the 
hope  which  drugs  may  artord  of  lessening  or  preventing  subsequent 
attacks.  In  such  a  dilemma  we  are  left,  as  physicians,  to  choose  from  the 
foUowino-  list  of  drugs,  such  as  seem  best  adapted  to  meet  the  indications  : 
(l),the  bromides  of  potassium,  sodium,  ammonium,  iron,  arsenic,  calcium, 
etc;  (2),  preparations  of  zinc,  preferably  the  oxide;  (3),  the  various 
preparations  of  arsenic;  (4),  the  nitrate  of  silver;  (5),  belladonna,  in 
some  of  its  various  forms;  (6),  hyoscyamus ;  (7),  osmic  acid;  (8),  digi- 
talis; (9),  curare;  (10),  the  nitrite  of  aniyl ;  (llj,  strychnia;  (12),  the 
hydrate  of  chloral;  (13),  the  iodides  of  potassium,  calcium,  and  iron 
(especially  if  syphilis  is  suspected  to  be  a  factor  in  the  case)  ;  and  (14) 
preparations  of  nitro-glycerine. 

The  bromides  of  sodium^  potassium,  lithium,  ammonium,  and  calcium 
probabl}'  stand  first  in  professional  estimation  to-day  as  a  remedy  in 
epileps}'.  These  salts  are  commonly  given  in  doses  which  vary  from 
fifteen  grains  three  times  a  day  at  the  commencement  to  one  hundred 
grains,  as  the  patient  becomes  tolerant  of  them.  They  are  preferably 
given  in  solution,  and  Seguin's  suggestion  that  Vichy  water  be  used  as 
a  solvent  is  a  good  one.  Gower's  method  is  to  give  ver}'  large  doses  at 
the  beginning  of  treatment  after  breakfast  in  a  goblet  of  water.  He 
advises  that  two,  three,  four,  five,  and  six  drachms  of  bromides  be  given 
on  successive  mornings.  He  omits  treatment  for  a  week  or  two  after  the 
patient  has  been  carried  to  a  state  of  drowsiness  or  of  mental  sluggish- 
ness. Subsequent!}',  he  gives  doses  of  twenty  grains  or  more  three  times 
a  day. 

Most  authorities  advise  the  continuance  of  the  bromides  for  two 
years  at  least.  A  late  author  sa3s,  "  Patients  may  take  sixty  to  ninety 
grains  of  bromide  a  day  for  six  or  ten  years  without  injury."  I  would 
caution  the  reader  against  so  extreme  a  statement.  I  ha^-e  seen  patients 
brought  to  a  state  of  insanity'  and  idiocy  by  very  heavy  doses,  and  all 
patients  become  more  or  less  affected  in  mental  power  by  its  long- 
continued  use.  Personally,  I  am  inclined  to  believe  that  the  apparent 
benefits  derived  from  the  use  of  bromides  is  more  than  counterbalanced 
in  most  cases  by  their  disastrous  effects  upon  the  nervous  system. 

If  a  skin  eruption  (acne)  appears,  arsenic  may  be  judiciously  given 
in  connection  with  the  bromides.  The  dose  of  Fowler's  solution  is  from 
three  to  five  drops  for  such  a  purpose. 

The  bromide  of  lithium  is  said  to  be  tolerated  by  weak  stomachs 
better  than  the  other  salts  mentioned. 

In  connection  with  the  bromide  treatment,  it  is  oftentimes  important 
that  patients  take  iron,  cod-liver  oil,  and  quinine.     It  is  also  well  to  stop 


TREATMENT   OF  EPILEPSY.  493 

indulgence  in  alcohol,  tea  and  coftee  to  excess,  highly-seasoned  and 
indigestible  food  (esijecially  of  an  animal  kind),  and  cold  bathing,  A 
regular  movement  of  the  bowels  should  be  had  daily.  This  may  be 
aided  by  the  drinking  of  mineral  waters,  or  by  the  hot-water  treatment 
(p.  248). 

In  nocturnal  epilepsy,  the  largest  dose  may  be  advantageously  given 
at  night. 

Hydrate  of  chloral  is  often  combined  with  bromides.  It  should  not 
be  continued  too  long,  as  it  attects  the  general  health.  The  dose  should 
not  exceed  fifteen  grains,  and  it  is  well  to  combine  digitalis  with  it,  to 
prevent  the  possibility  of  heart  symptoms. 

Belladonna  was  first  recommended  highly  by  Trousseau  in  the  treat- 
ment of  epilepsy.  Atropine  is  now  generally  used  in  doses  of  one  one- 
hundredth  of  a  grain.  This  dose  may  be  given  three  times  a  day  until 
the  pupils  become  dilated  and  the  throat  unnaturally  dr3^ 

The  satis  of  zinc,  chiefly  the  oxide  and  the  bromide,  have  been 
extolled  as  a  cure  for  epilepsy.  The  bromide  may  be  given  in  simple 
syrup  and  water,  commencing  with  one-grain  doses  and  increasing  the 
amount  gradually  as  long  as  nausea  is  not  produced.  The  oxide  is  given 
in  doses  of  from  five  to  ten  grains.  If  an  eruption  follows  its  use,' 
combine  it  with  Fowler's  solution  of  arsenic. 

The  nitrate  of  silver  is  liable  to  produce  a  permanent  blue  staining 
of  the  skin.  Its  supposed  benefits  hardlj'  warrant  so  great  a  risk ; 
hence,  it  should  not  be  continued  long,  in  case  it  be  employed. 

Curare  has  been  given  by  the  h^ypodermic  method  to  epileptic 
patients  in  doses  of  0.03  grammes  b^'  Kunze  and  others.  It  is  not  to  be 
administered  oftener  than  the  fifth  day.  It  shows  its  toxic  eftects  early 
in  the  eyes,  sight  being  rendered  dim  and  indistinct. 

Osmic  acid  (in  doses  of  0.002  grammes)  may  be  advantageously 
administered  in  combination  with  the  bromides,  according  to  the  late 
publications  of  Wildermuth. 

Finally,  nitrite  of  amyl  maj-  be  used  by  epileptics  as  a  means  of 
warding  off  impending  attacks.  It  is  best  carried  in  small  bulbs  of 
thin  glass  (amjd-pearls)  which  may  be  crushed  in  the  handkerchief 
and  the  fumes  inhaled  by  the  patient  as  soon  as  the  aura  is  perceived. 
Two  to  five  drops  of  this  agent  will  generall}'  prevent  an  attack  for 
a  while. 

Nitro-glycerine  as  a  therapeutic  agent  in  epilepsy  was  first  employed 
by  Hammond  and  Weir  Mitchell.  The  favorable  results  claimed  for  this 
agent  seem  to  have  fallen  far  short  of  general  acceptance.  The  late 
report  of  Osier  respecting  its  effects  in  epilepsy  seems  to  sliow  that  the 
remedy  rapidly  lost  its  influence  in  those  cases  that,  for  a  time,  appeared 
to  improve. 


494  LECTURES   ON   NERVOUS   DISEASES. 

It  may  be  given  in  pilules  of  ^Jo  <^^  '^  g^'ii")  or  in  a  one  per  cent, 
solution  in  doses  of  ttlv.  The  susceptibility  of  ditlerent  patients  to  this 
drug  varies,  according  to  my  experience  ;  hence,  it  is  wise  to  begin  with 
small  doses,  and  to  slowly  increase  the  dose  until  its  physiological 
eflects  are  manifested  by  a  flushing  of  the  face,  a  sense  of  fullness  in  the 
head,  and  a  peculiar  glow  of  the  whole  body. 

Finally,  when  the  condition  known  as  the  "  status  epilepticus " 
develops,  during  which  the  convulsive  attacks  are  practicall}''  constant, 
it  is  Avell  to  treat  the  patient,  according  to  circumstances,  by  ice  to  the 
spine,  inhalations  of  nitrite  of  amyl  or  chloroform,  repeated  doses  of 
chloral,  or  subcutaneous  injections  of  morphia. 

CHOREA. 

This  form  of  functional  nervous  disturbance  is  most  commonly 
encountered  in  children.  It  may,  however,  begin  in  adult  life ;  and  it 
has  been  known  to  develop  in  advanced  age.  It  is  commonly  known 
among  the  laity  as  "  St.  Vitus'  dance." 

Etiology.— This  disease  may  be  congenital.  It  is  particularly 
common  in  the  ortspring  of  tuberculous  parents.  The  period  of  second 
dentition  (the  sixth  and  seventh  years)  is  one  that  is  apparently  very 
susceptible  to  these  attacks.  I  have  several  times  observed  it  in  adults 
between  the  fifteenth  and  twenty-fifth  year  of  age ;  and  in  old  age  it  has 
been  often  known  to  follow  grief,  fright  and  violent  mental  emotions.  A 
predisposition  to  chorea  seems  to  exist  in  subjects  that  have  had  isolated 
cases  of  hysteria,  epilepsy,  insanity  and  neurasthenia  among  different 
branches  of  their  family. 

Most  authorities  mention,  among  the  exciting  causes  of  this  disease, 
excessive  joy  or  grief,  severe  fright,  traumatisms  to  the  head  or  back, 
infectious  diseases,  rheumatism,  anaemia,  onanism,  reflex  irritation  aris- 
ing from  the  genitals,  the  intestine,  neuromata,  dentition,  pregnancy, 
etc.;  and,  finally,  certain  atmospheric  conditions.  It  seems  to  be  some- 
what more  common  among  girls  than  boys.  It  may  be  acquired  by 
imitation. 

In  the  light  afforded  by  the  latest  researches  in  reference  to  the 
existence  of  eye-defect  as  a  cause  in  producing  chorea,  as  well  as 
the  so-called  "  predisposition"  thereto,  the  following  deductions  of 
Dr.  Stevens'  seem  to  prove  quite  conclusively  that  hyperopia  (often 
latent)  exists  in  an  enormous  proportion  of  choreic  subjects^  and  that 
muscular  error  in  the  orhit  frequently  coexists.  From  the  prize  essay  of 
that  author  the  following  deductions  are  taken  : — 

In  118  cases  of  chorea,  78  had  simple  hyperopia  (or  about  67  per 
cent.);  13  had  hyperopic  astigmatism  (or  about  11  per  cent.);  5  had 
mixed  astigmatism  (or  about  4  per  cent.) ;  6  had  unequal  myopia  in  the 


CHOREA.  495 

two  eyes  (or  about  5  per  cent.) ;  11  bad  ni3'opic  astigmatism  (or  about  *J 
per  cent.);  5  had  no  marked  refractive  error,  but  a  marked  muscular 
defect  existed  in  the  orbit  (or  about  4  per  cent.). 

It  will  be  seen  from  these  statements  that  nearly  eight^y  per  cent,  of 
the  subjects  examined  by  tliis  author  (and  the}-  were  consecutive  cases) 
exliibited  eitlier  simple  hyperopia  or  h^'peropic  astigmatism,  and  that 
four  per  cent,  more  had  mixed  astigmatism,  which  entitles  them  to 
belong  to  this  class  of  refractive  error.  Onlj^  fourteen  })er  cent,  had 
myopia  or  myopic  astigmatism.  Onl}^  four  per  cent,  had  no  refractive 
error;  and  these  had  a  sufficient  degree  of  ocular  insufficiency'  to  justify 
the  view  that  reflex  irritation  from  the  visual  apparatus  was  markedly 
present.  In  not  a  single  case  were  the  e^es  perfectly  emmetropic  and 
the  ocular  muscles  in  the  state  of  physiological  equilibrium. 

My  own  personal  experience  with  choreic  patients  of  a  persistent 
type  leads  me  to  sustain  in  a  general  way  the  accuracy  of  these  observa- 
tions. They  are  oftentimes  difficult  subjects  to  examine  with  satisfac- 
tion, partly  on  account  of  their  age,  and  partl}^  on  account  of  the 
spasmodic  movements  of  the  head  and  body.  I  have  found  "  latent  " 
hyperopia  of  a  high  degree  in  all  of  m}^  later  cases  whose  eyes  I  have 
examined,  not  infi-equently  associated  with  esophoria  and  hyperphoria. 
This  subject  will  be  more  full}-  discussed  when  the  treatment  of  this 
disease  is  reviewed. 

Morbid  Anatomy. — The  changes  which  exist  in  the  brain  or  spinal 
cord  in  connection  with  chorea  are  unknown.  It  is  very  doubtful,  to  my 
mind,  if  an^'^  exist.  All  theories  in  relation  to  it  are  either  pure 
assumptions,  or  are  based  upon  insufficient  data. 

Symptoms. — Various  prodromal  S3'mptoms  of  this  disease  are  men- 
tioned by  authors.  Among  these  the  following  may  be  given : 
Anorexia,  a  disinclination  toward  mental  or  bodily  pursuits,  headache, 
restlessness,  pains  in  the  limbs  and  joints,  irritability  of  temper,  weak- 
ness of  the  memory,  and  many  others. 

As  the  disease  develops,  the  patient  gradually  begins  to  exhibit  a 
certain  awkivardness  of  movement  in  the  extremities.  Objects  fall 
frequently  out  of  the  grasp.  The  child  spills  his  food  while  eating.  It 
becomes  difficult  for  the  child  to  stand  still.  Attempts  to  write,  sew  or 
draw  are  imperfectly  performed.  Such  children  are  very  often  punished 
for  supposed  ill  behavior  or  careless  habits. 

Later  on,  the  symptoms  become  so  unmistakable  that  the  presence 
of  actual  disease  is  no  longer  doubted.  The  patient  may  become  inca- 
pable of  dressing.  The  limbs  or  face  are  no  longer  under  the  control  of 
the  will.  Involuntary  movements  of  extension  and  flexion  of  the  fingers, 
pronation  and  supination  of  the  hand,  shrugging  of  the  shoulders, 
dancing  of  the  legs,  grimaces  of  the  face,  and  distortions  of  the  body 


496  LECTURES   ON  NERVOUS   DISEASES, 

become  more  or  less  constant.  These  patients  may  be  unable  to  sit  upon 
a  chair  without  feeling  a  sense  of  danger  from  falling.  I  have  known  a 
child  to  be  thrown  out  of  bed  by  the  violence  of  the  spasmodic 
movements. 

Speech,  mastication,  and  swallowing  may  be  seriously  embarrassed, 
and  the  teeth  have  been  known  to  be  broken  by  the  uncontrolled 
movements  of  the  jaw. 

The  thoracic  and  abdominal  muscles  may,  in  rare  instances,  be  so 
seriously  attected  as  to  produce  cyanosis  and  a  sense  of  impending 
suftbcation;  but  I  have  never  seen  any  affection  of  the  heart,  the  bladder, 
or  the  rectum  in  chorea.  Even  the  glottis  ma}^  participate  in  the 
convulsive  movements. 

During  sleep,  the  convulsive  movements  usually  entirely  cease. 
They  are,  however,  sometimes  very  severe  just  preceding  repose;  hence 
these  subjects  often  regard  bed-time  with  a  peculiar  horror. 

Strange  as  it  may  seem,  these  movements  seldom  create  fatigue  ; 
although  the}^  ma}'  be  incessant. 

The  whole  bod}'  is  not  usually  affected  until  late  in  the  disease. 
Often  a  condition  (known  as  "  hemi-chorea  "),  in  which  the  muscles  on 
the  right  or  left  side  are  alone  uncontrolled,  is  dcA^eloped.  Again,  one 
arm  and  the  face,  or  the  face  alone,  may  be  affected.  The  left  side  is 
usually  more  severely  attacked  than  the  right. 

The  mental  state  of  these  subjects  is  generally  far  below  the  normal 
standard.  They  are  prone  to  laughter  over  trivial  things,  or  to  attacks 
of  weeping  without  apparent  cause.  They  may  develop  idiocy  or  mania. 
Irritability  of  temper,  a  stupid  demeanor,  and  impairment  of  memory 
are  frequently  observed. 

Any  unusual  excitement  of  the  mind  or  body  is  apt  to  intensify  the 
muscular  twitchings.  Severe  mental  application,  the  reading  of  exciting 
books,  the  witnessing  of  dramas  or  other  entertainments  of  that  char- 
acter, excessive  indulgence  in  sports,  etc.,  are  to  be  discountenanced, 
therefore,  in  cases  of  chorea. 

Choreic  subjects  are  apt  to  be  pale  and  anjiemic.  It  is  not  uncom- 
mon, therefore,  to  detect  an  anemic  murmur  over  the  heart  and  the 
jugulars.     Sometimes  the  second  sound  of  the  heart  is  intensified. 

It  is  difficult  to  carefully  observe  the  pulse  in  chorea  on  account  of 
the  spasmodic  movements.  It  has  been  stated  that  the  arterial  tension 
is  diminished  in  the  height  of  the  disease. 

I  have  never  observed  any  change  in  the  bodily  temperature  which 
might  be  regarded  as  directly  due  to  chorea.  An  elevation  of  the 
temperature  of  the  parts  affected  has  been  noted  by  some  observers  in 
hemi-chorea ;  but,  in  my  experience,  this  is  not  always  present. 

In  serious  cases,  insomnia  may  develop. 


CHOEEA.  497 

Complications.— Basedow's  disease  may  be  developed  in  connection 
■with  chorea.  Aphasia  has  been  observed  as  a  comi)lication  of  this 
affection;  and,  in  rarer  instances,  paralysis  of  a  transient  character  has 
been  known  to  develop.  The  joints  may  become  swollen  and  painful. 
The  pupils  may  be  rendered  sluggish  to  the  effects  of  strong  light,  and 
be  unnaturally  dilated.  Disturbances  of  the  intellectual  faculties  have 
been  known  to  occur  during  chorea,  and  to  cause  permanent  idioc}'  or 
insanity. 

Diagnosis. — This  disease  may  be  confounded  Avith  athetosis,  post- 
paralytic chorea,  hysteria,  convulsive  tremor,  paralysis  agitans,  mul- 
tiple spinal  sclerosis,  and  some  other  forms  of  organic  disease  of  the 
brain  and  spinal  cord.  The  table  on  the  following  page  will  aid 
the  reader  in  distinguishing  between  chorea  and  most  of  these 
affections. 

The  age  which  is  generally  attacked  in  choreic  subjects  practically 
removes  all  the  difficulties  of  diagnosis.  It  is  only  in  adult  cases  that 
we  are  called  upon  to  discriminate  closely  between  it  and  hj'steria, 
convulsive  tremor,  paralysis  agitans,  and  multiple  sclerosis. 

The  chief  point  in  all  of  these  discriminations  bears  upon  the  relation 
of  choreic  movements  to  willed  muscular  movements  of  the  extrem- 
ities. In  chorea,  willed  muscular  action  is  unexpectedh^  opposed  by 
spasmodic  movements  which  carry  the  i)art  in  some  unnatural  direction. 
In  this  respect  the  disease  simulates  incoordination  of  movement  (which 
is  prominently  encountered  in  locomotor  ataxia).  Thus,  for  example,  a 
choreic  subject  Avhile  eating  will  jerk  a  spoon  away  as  it  is  about  to  enter 
the  mouth ;  or,  he  may  possibly  strike  the  ear  or  nose  with  the  fork. 
Such  accidents  are  seldom  observed  when  tremor  exists,  or  when  even  in 
athetosis. 

Prognosis.  —  Although  fatal  cases  of  chorea  have  been  recorded, 
the  prognosis  is,  as  a  rule,  extremely''  favorable.  Quite  a  large  pro- 
portion of  cases  recover  under  judicious  medication  within  ten  weeks. 
Obstinate  insomnia  is  a  symptom  of  evil  import.  I  have  seen  some 
very  persistent  cases  of  chorea  in  the  adult  which  have  withstood 
all  medication,  and  have  subsequently  made  a  complete  recovery 
when  the  ej^e-muscles  have  been  i)roperly  balanced  bj-  partial  tenoto- 
mies ;  and  I  regard  the  correction  of  refractive  errors  in  all  cases  of 
chorea  as  a  step  of  vital  importance.  It  certainly  tends  to  prevent 
relapses,  wnich  are  particularly  prone  to  occur  in  chorea.  I  believe 
the  mental  impairment  often  noted  in  connection  with  this  disease 
to  be  due  in  a  large  proportion  of  the  cases  to  "  e3^e-strain "  un- 
corrected. A  hyperopia  or  hyperopic  astigmatism  in  a  child  is  cer- 
tainl}^  a  defect  of  suflflcient  importance  to  merit  earlj'  recognition  and 

correction, 

83 


498 


LECTURES   ON   NERVOUS   DISEASES. 


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CHOEEA.  499 

The    following   case  illustrates    tiie    importance  of  correction    of 
anomalies  of  the  visual  apparatus: — 

Chronic  Chorea  of  Thirty-one  Years  Duration,  affecting  the  Head,  Face,  and  all  the 
Extremities. — Female,  aged  thirty-three,  unmarried. 

Family  History. — The  father  had  puhnonary  hemorrhages  for  many  years.  One 
paternal  aunt  died  of  "hasty  consumption.''  Sick-headaches  are  very  common  amont' 
both  paternal  and  maternal  ancestors.  Neuralgia  is  a  frequent  comj)laint  among  the 
paternal  ancestors. 

When  two  years  of  age,  this  girl  develojied  chorea.  The  spasmodic  twitchings 
steadily  grew  worse,  in  spite  of  the  fact  that  her  father  was  a  physician,  and  that  she  had 
the  services  of  the  most  skillful  medical  men  from  time  to  time.  The  twitchings  began  on 
the  right  side ;  but  they  subsequently  involved  the  left  side,  and  also  the  head  and  face. 

She  has  suffered  some  from  sick-headaches,  as  has  also  her  sister.  The  hajids  haiJC 
f/radiially  become  so  contractured  that  all  attempts  to  use  them  are  more  or  less  distressing. 
Her  fingers  could  not  be  extended  farther  than  would  suffice  to  grasp  small  objects. 

When  I  first  saw  this  patient  she  was  unable  to  write  except  by  grasping  the  pencil 
with  all  the  fingers  and  the  palm  of  the  left  hand,  and  holding  the  left  hand  with  the  right 
hand  as  the  spasmodic  movements  of  writing  were  made.  She  walked  with  a  peculiar 
unsteady  and  crab-like  gait,  ate  with  difficulty,  and  suffered  great  pain  between  the 
shoulder-blades  and  over  the  first  lumbar  vertebra  (two  points,  by  the  way,  which  are 
very  frequently  attacked,  in  my  experience,  when  eye-strain  is  present).  She  had  never 
written  with  ink.  Prior  to  menstruation  (which  occurred  at  seventeen  years  of  age)  the 
patient  had  experienced  attacks  (probably  epileptic)  which  she  describes  as  "those  of 
numbness,  followed  by  a  loss  of  consciousness."  She  has  had  chronic  constipation  all  her 
life.     The  memory  and  mental  faculties  are  perfect. 

When  I  first  saw  this  patient  the  spasms  were  very  violent,  especially  about  the  face 
and  neck.  The  limbs  were  jerked  about,  the  fingers  too  tightly  clinched  at  times  to  grasp 
anything,  and  the  speech  was  rendered  peculiarly  spasmodic  and  almost  unintelligible  at 
times.     She  sputtered,  and  at  times  ejected  drops  of  saliva,  when  endeavoring  to  converse. 

At  the  first  examination  she  exhibited  no  refractive  error ;  but,  under  atrojiine,  a  high 
degree  of  hyperopia  (r75  D.)  was  detected,  and  proper  spherical  glasses  (+  1  D.)  were 
at  once  provided.  In  order  to  test  her  eye-muscles,  the  services  of  Professor  J.  Williston 
Wright,  of  New  York  city,  who  saw  her  with  me  by  invitation,  were  invoked  to  hold  her 
head.  This  he  did  with  no  small  effort  by  clasping  the  head  on  either  side,  and  firmly 
pressing  her  head  a^jainst  his  body  as  he  stood  behind  her  chair.  During  this  examina- 
tion she  whistled  shrill  notes  on  two  occasions,  and  underwent  the  most  violent  facial 
and  body  contortions. 

The  results  of  this  imperfect  examination  (necessarily  so  under  such  conditions) 
indicated  to  me  that  a  high  degree  of  hyperphoria  existed ;  and,  a-s  I  could  not  again  see 
the  patient  for  some  months,  I  decided  to  perform  a  free  tut  incomplete  division  of  the  left 
inferior  rectus  muscle.  I  then  instructed  the  patient  to  try  and  get  a  photograph  taken,  if 
possible,  before  she  saw  me  again.  She  laughingly  said  that  she  had  never  been  able  to 
have  a  picture  taken,  but  she  would  do  so  if  she  could.  She  then  departed  for  home 
with  instructions  to  return  to  me  for  treatment  in  the  autumn.  The  first  picture  received 
of  this  case  was  one  that  she  was  able  to  have  taken  three  weeks  after  the  operation,  when 
her  head  and  shoulders  had  become  comparatively  calm,  as  a  result  of  the  relief  afforded 
by  it.  This  photograph  was  deemed  at  that  time  a  great  success  by  herself  and  friends. 
You  can  see  in  it  the  blurred  outlines  which  indicate  that  the  movements  wfre  still  some 
what  active. 


500  LECTURES   ON   NERVOUS  DISEASES. 

During  the  past  autumn  this  patient  has  been  under  my  care  for  some  eight  weeks.  I 
have  partially  divided  the  right  superior  rectus  and  both  externi  in  order  to  overcome  a 
high  degree  of  left  hyperphoria  and  exophoria,  and  I  have  administered  static  sparks  daily 
to  the  spine  and  limbs.  The  second  picture  will  give,  better  than  words  can  describe  it,  an 
idea  of  the  wonderful  improvement  which  has  taken  place.  Prior  to  her  departure  for  home 
(some  weeks  since)  she  could  thread  the  finest  cambric-needle,  and  pass  her  fare  to  the  con- 
ductor of  a  street  car  without  attracting  the  notice  of  passengers,  or  throwing  it  out  of  the 
window,  as  she  certainly  would  have  been  apt  to  do  two  months  previously.  She  can  fully 
extend  her  fingers,  walk  several  miles  a  day,  write  with  far  greater  certainty  and  ease,  and 
eat  at  a  boarding-house  table  without  exciting  comment.  Her  limbs  still  twitch  somewhat 
immediately  before  going  to  sleep,  and,  in  the  presence  of  strangers  or  when  unduly 
excited,  she  still  shows  some  spasmodic  movements  of  the  face  and  shoulders.  When  calm 
she  is,  however,  perfectly  composed,  and  almost  entirely  free  from  convulsive  movements, 
She  considers  herself  as  practically  cured ;  but  I  suspect  that  time  and  some  further 
operative  work  upon  the  eye-muscles  will  be  demanded  before  complete  restoration  to 
health  is  effected. 

As  I  regard  this  case  as  one  of  the  most  distressing  and  typical 
cases  of  chronic  chorea  ever  reported,  it  may  be  well  to  state  that  the 
patient  is  well  known  to  Professor  A.  M.  Phelps  and  Professor  J.  W. 
Wright,  of  this  city,  and  Professor  Woodward,  of  Burlington,  Yt.,  and 
that  she  has  been  seen  by  many  members  of  the  profession,  both  from 
this  city  and  distant  States,  during  her  treatment  in  m}'  office. 

During  the  whole  treatment  of  this  patient  no  drugs  have  been 
employed,  and  the  photographs  are  from  untouched  negatives.  I 
attribute  to  the  static  applications  the  rapid  relief  of  the  contractured 
state  of  the  fingers  and  the  improvement  in  her  general  strength ;  but, 
from  many  facts  observed  during  my  treatment  of  her.  I  am  convinced 
that  the  relief  of  the  eye-strain  is  alone  deserving  of  whatever  credit 
may  be  claimed  for  her  recover}'.  Four  weeks  before  she  was  dismissed 
from  my  care  she  read  and  sewed  continuously  for  several  days,  and  was 
immediately  precipitated  into  a  relapse,  which  as  rapidly  subsided  when 
the  cause  was  ascertained  and  its  recurrence  prevented. 

Treatment. — My  remarks  concerning  the  causes  of  chorea  and  those 
which  treat  of  the  surgical  relief  of  epilepsy  bear  strongly  upon  the 
cure  of  this  form  of  functional  nervous  disturbance.  I  have  not  yet 
encountered  a  case  for  the  past  three  years  in  my  private  practice  where 
I  have  failed  to  find  eitlier  a  refractive  error  or  an  insufficiency  of  some 
of  the  eye-muscles.  It  has  been  my  custom  for  some  time  past  to  care- 
fully examine  the  eyes  of  these  cases  under  atropine,  and  to  correct  all 
refractive  errors  (so  found)  subsequently  with  a  glass  that  the  patient 
could  comfortably  wear  after  the  etiects  of  atropine  had  subsided. 

In  previous  pages  of  this  work,  I  have  combated  the  view  (too 
commonly  held  b}^  oculists)  that  the  ophthalmoscope  furnishes  as  positive 
information  in  respect  to  hyperopic  defects  as  the  ordinary  type-tests 
made  when  the  eye  is  fully  under  the  effects  of  atropine.     I  have  time 


CHOEEA.  501 

and  time  ao:ain  found  the  best  experts  to  be  in  error,  when  they  have  too 
implieitlv  relied  upon  opiithalmoscopic  tests. 

All  that  any  one  can  determine  with  this  instrument  is  based,  of 
necessity,  upon  the  presumption  that  tha  jjatienVs  accommodation  as  well 
as  that  of  the  observer  is  relaxed.  This  factor  in  the  case  is  therefore 
two-fold;  and  is  not  always  overcome,  on  the  one  hand,  by  an  "acquired 
faculty  "  of  the  oculist,  or,  on  the  other  hand,  by  directing  the  patient  to 
look  at  an  object  over  twenty  feet  from  the  patient's  eye.  To  be  sure  of 
your  results  you  must  be  able  in  any  case  to  state  positively  that  no 
accommodative  efforts  are  made  b}'^  the  patient.  This  is  positively 
ensured  by  a  free  use  of  atropine,  and  by  no  other  recognized  method. 

Again,  the  tests  for  suspected  errors  in  the  eye-muscles  are  valueless, 
unless  the  refractive  errors  be  intelligently  corrected  first.  Moreover, 
if  any  muscular  defect  is  detected,  and  confirmed  by  repeated  examina- 
tions, the  use  of  prismatic  glasses  does  not  fully  meet  the  indications  ; 
because  we  have  no  way  (yet  known  to  science)  of  estimating  the  amount 
of  "  latent  "  insufficienc}-  which  may  exist  in  each  case. 

The  results  obtained  by  partial  tenotomies  prove  the  truth  of  this 
statement  beyond  the  possibilitj'  of  its  denial. 

Respecting  the  relationship  of  chorea  to  anomalies  of  the  visual 
apparatus  I  would  make  the  following  suggestions : — 

(1)  Choreic  subjects  belong  to  one  of  two  classes:  (a)  Those  who 
tend  to  get  well  under  almost  any  treatment  or  even  without  treatment, 
and  (ft)  those  who  fail  to  get  relief  from  any  medicinal  aid.  The  latter 
tend  to  run  a  chronic  course,  usually  one  of  unfavorable  progression, 

(2)  The  chronic  form  of  chorea  is  one  of  the  most  serious  and 
hopeless  of  nervous  maladies.  It  is  not  infrequently  associated  with 
epilepsy  or  with  mental  impairment. 

(3)  Both  forms  of  chorea  are  based,  as  a  rule,  upon  a  well-marked 
neuropathic  or  tubercular  predisposition. 

(4)  The  pathology  of  chorea  is  not  known.  No  one  has  ever  proved 
that  it  was  a  "  constitutional  disease,"  in  the  sense  that  an  organic  lesion 
was  essential  to  its  development. 

Now,  the  remarkable  case  which  I  report  belonged,  without  question, 
to  the  class  which  I  think  is  generally  regarded  by  neurologists  as 
incurable,  and  as  offering  but  little  hope  of  marked  improvement  under 
any  form  of  medication.  In  this  girl,  at  least,  all  such  attemjits  at  relief 
had  proved  of  no  benefit.  The  convulsive  movements  had  persisted  for 
over  thirty  years,  and  the  condition  of  the  patient  has  steadily  grown 
worse  in  spite  of  the  best  medical  care.  She  had  probably  had  a  few- 
epileptic  seizures  in  girlhood,  but  her  mind  had  remained  unimpaired. 

When  Dr.  G.  T.  Stevens  read  his  paper  on  the  relationship  between 
refractive  errors  and  chorea  in  1876,  he  advanced  views  that  were  new 


502  LECTURES   ON   NERVOUS  DISEASES. 

to  the  profession.  Within  a  year,  a  paper  on  the  same  snl)ject  was 
published  by  another,*  in  which  the  view  of  Dr.  Stevens,  that  hyperopia 
constituted  an  inii)ortant  element  in  most  cases  of  chorea,  was  very 
strongly  combated.  The  latter  paper  has  been  quite  extensively  quoted. 
It  may  not  be  inappropriate  for  me,  therefore,  to  carefully  analyze  the 
paper  referred  to  in  this  connection,  as  I  feel  that  the  conclusions  of  the 
critical  reviewer  are  misleading,  aud  certainly  not  in  accord  with  mj' 
own  observations. 

This  observer  drew  his  conclusions  from  an  examination  of  thirty-one 
cases  of  chorea,  most  of  which,  if  not  all,  were  taken  from  disi)ensaries. 
It  is  safe  to  infer,  therefore,  that  the  patients  were  not  well  educated. 
Thej'^  may  not  have  even  known  their  letters  sufticiently  well  to  be 
regarded  as  accurate  in  reading  test-type. 

In  the  second  place,  the  ages  of  the  thirty-one  patients  reported 
show  that  twenty -two  were  less  than  twelve  years  of  age.  Four  were  six 
years  of  age,  and  one  was  only  three  and  a  half;  one  was  seven,  three 
were  eight,  three  were  nine,  four  were  ten,  and  six  were  eleven  years  old. 
The  question  naturally  arises  whether  (at  these  ages)  the  tests  of  vision 
usually  made  by  the  aid  of  test-types,  when  the  patient  is  well  under 
atropine,  are  reliable  in  children  that  are  presumably  ignorant. 

In  the  third  place,  seventeen  out  of  the  thirt3'-one  patients  were 
found  to  be  emmetropic  in  one  eve  or  both  when  atropine  was  used  b}- 
this  observer.  This  is  certainly  a  very  remarkable  fact,  as  it  is  a 
])roportion  which  is  contradicted  by  statistics  gathered  b}^  equally 
competent  observers  from  the  examination  of  children's  e3'es  under 
atropine. f 

In  the  fourth  place,  the  percentage  of  hj'peropia  and  hyperopic 
astigmatism  conil)ined  constitutes,  according  to  this  observer,  about  55 
per  cent,  of  the  total  number.  No  myopia  or  myopic  astigmatism  was 
detected  in  any  of  the  thirty-one  cases.  The  latter  fact  is  remarkable, 
and  seems  to  cast  further  doubt  upon  the  cases  reported  as  "  emmetropic." 

Again,  nineteen  of  the  thirty-one  patients  are  reported  as  having 
had  "  insutliciency  of  the  interni."  Now,  I  have  examined  within  the 
last  three  years  the  eyes  of  a  very  large  number  of  patients  who  were 
affiicted  with  various  nervous  disorders,  and  I  have  given  special 
attention  to  the  state  of  the  e^ye-mnscles  detected  by  appropriate  tests  in 
these  cases.     I  have  found  the  condition  of  "  insutliciency  of  the  interni  " 

*  Dr.  C.  S.  Bull,  3frd.  Record,  June,  1877. 

t  Cohn  shows  that,  in  299  eyos  under  atropine,  no  case  of  absolute  erametropia  was 
detected.  Hansen  found  but  26  emmetropic  eyes  in  KilO,  and  Diirr  but  30  in  414.  A. 
Randall  states,  in  his  article  on  *'  The  Refraction  of  the  Human  Eye,  a  Critical  Study  of 
tlie  Examinations  of  the  Refraction,  especially  among-  School-children  "  (^Am.Jo'iir.  of  the 
3fca.  fS'cL,  July,  1885),  that  only  7  faa  pt!r  cent,  of  1834  eyes  of  infants  and  school-children 
were  found  to  be  emmetropic. 


CHOEEA.  503 

to  be  a  coinparativelj'  rare  one  when  Graefe's  test  was  employed  with 
the  test-object  (preferably  a  candle-tlanie),  at  twenty  feet  from  the  eye. 
It  is  reasonable  to  infer,  therefore,  that  the  tests  made  by  this  observer 
were  such  as  to  require  accommodative  efforts  (probably  the  line-and-dot 
test  at  foux'teen  inches).  Such  tests,  if  made  under  atropine,  are  cer- 
tainly open  to  criticism  and  probable  cori-ection.  Even  if  not  made  nnder 
ati'opine,  this  form  of  test  is  only  of  value  in  connection  with  the  other. 

The  critical  reviewer  mentions  a  certain  "  Martin  family  "  as  a  proof 
to  his  mind  that  a  "  neurotic  taint  "  exists  in  choi-eic  subjects.  Now,  the 
four  clioreics  of  this  family  were  all  hyperopic,  while  five  who  were  not 
so  had  no  chorea.  This  fact  would  seem  to  confirm  Dr.  Stevens'  view. 
No  one  disputes  the  fact  that  a  "  neurotic  predisposition  "  is  present  in 
most  choreic  subjects ;  but  tiie  view  that  eye-defect  tends  to  create  this 
tendency  seems  to  l)e  less  generally'  accepted. 

Finally,  the  paper  here  referred  to  notes  a  failure  to  relieve  the 
chorea  by  the  use  of  glasses,  in  a  few  cases  where  the  patients  were  able 
to  purchase  them.  If  otlier  serious  defects  existed  besides  the  hyperopia 
(to  the  extent  shown  in  the  examinations  reported  by  this  observer), 
this  is  not  to  be  wondei'ed  at.  Hyperopic  glasses  will  not  relieve 
"  insufticiency  of  the  interni  "  (frequently  noted  by  this  observer  in  his 
choreic  subjects);  and  the  latter  is  certainly  a  well-accepted  cause  of 
reflex  disturbance  when  it  exists,  as  well  as  the  latent  hyperopia  that 
was  alone  corrected. 

In  preparing  this  section,  I  have  looked  carefully  over  the  records 
of  all  cases  of  chorea  which  I  have  personally  tested  for  anomalies  of 
the  visual  apparatus.  I  have  not  found  a  single  case  where  either 
•'  manifest  or  "  latent  "  hj'pcropia  did  not  exist.  I  do  not  mean  to  assert 
that  this  statement  proves  anything — but  it  certainly  seems  a  ver^' 
strange  coincidence,  if  such  it  is. 

Respecting  the  "  neurotic  taint  "  to  which  this  reviewer  attributes 
the  origin  of  chorea,  I  would  respectfully-  refer  my  hearers  to  a  study  of 
this  question  and  its  dependency  upon  anomalies  of  the  visual  apparatus 
in  a  paper  previously  quoted  from,*  and  also  to  tables  of  a  similar 
purport  published  (since  that  article  was  read  at  the  International 
Medical  Congress)  by  G.  T.  Stevens,  in  his  work  an  "  Functional  Nervous 
Diseases,"  f 

Evei'y  patient  whom  you  examine  for  defective  equilibrium  in  the 
eye-muscles  instinctively  strives  (not  by  mere  volition)  to  get  binocular 
vision,  under  the  nearest  appi-oach  to  physiological  conditions  of  which 
he  is  capable. 

We  are  forced  to  admit,  therefore,  that  what  we   detect   in    any 
patient  and  record  as  an  error  is  in  reality  only  what  the  patient  cannot 
*Med.  Register,  November  19, 1877.     f  D.  Appleton  &  Co.,  N.  Y.,  1887. 


504  LECTURES   ON   NERVOUS   DISEASES. 

conceal,  not  necessarily  all  the  defect  in  the  muscles  that  actually 
exists. 

Because  a  patient  can  momentarilj'  perform  a  feat  of  eye-balance 
which  approaches  the  normal  state,  by  the  aid  of  his  reserve  power, 
it  is  by  no  means  proved  that  the  eyes  are  habitually  in  equilibrium. 
An  over-taxed  muscle  may,  and  often  does,  become  preternaturally 
shortened  or  "  contractured,"  so  long  as  its  utmost  exertions  are  habitu- 
ally demanded.  Why,  then,  may  this  condition  not  exist  in  the  eye- 
muscles,  when  the  antagonistic  forces  are  unequally  balanced  ?  If  it  may 
do  so,  does  this  view  not  tend  to  shed  some  light  upon  the  fact  that 
patients  often  show  a  higher  degree  of  "  insufficiency  "  after  a  tolerably 
free  division  of  the  stronger  tendon  than  before  the  operation  ?  May 
not  a  contractured  muscle  relax  when  relieved  of  the  irritation  caused  by 
the  over-taxed  condition  of  that  muscle  ?  May  not  the  development  of 
"  latent  "  insufflcienc}'  be  attributed  (in  part  at  least)  to  the  relaxation 
of  a  muscle  in  the  orbit,  which  has  been  thrown  into  a  state  of  abnormal 
spasm  by  its  efforts  to  overcome  an  antagonistic  force  disproportionate 
to  its  inherent  strength  ?  I  propound  these  questions  because  many 
facts  have  been  observed  by  me  after  partial  tenotomies  upon  the  eye- 
muscles,  which  seem  to  me  to  add  confirmator3'  evidence  in  support  of 
this  view.  If  there  exists  in  any  case  a  tendency  on  the  part  of  the  visual 
axes  to  deviate  from  their  normal  condition  of  parallelism  when  the  eyes 
are  directed  at  an  object  twent}'  feet  or  more  from  the  eye,  may  it  not 
indicate  that  an  inherent  defect  (probably  congenital)  exists  in  the 
weaker  muscles,  either  in  respect  to  their  actual  development  or  their 
contractile  power?  If  this  view  is  admitted,  why  ma\'  not  such  a 
muscle,  by  endeavoring  to  antagonize  a  stronger  muscle,  become  con- 
tractured in  consequence  of  the  development  of  the  state  of  excessive 
nervous  irritability  ? 

Clinically,  as  I  have  remarked  before,  we  are  forced  to  recognize  two 
classes  of  choreic  patients, — those  who  get  well  within  a  short  time 
(usually  in  less  than  four  months)  by  the  aid  of  tonics,  good  food,  etc.,  and 
possibly  without  any  medication;  and  those  of  a  chronic  type,  in  whom 
the  choreic  manifestations  persist  in  spite  of  every  form  of  medication. 

There  is  no  nervous  disease  known  which  has  apparently  been  cured 
by  so  many  different  and  often  antagonistic  lines  of  treatment.  Some 
get  well  under  iron,  some  under  arsenic,  some  by  the  aid  of  good  diet  and 
good  air.  All  the  remedies  which  have  been  extolled  as  curative  agents 
would,  if  compiled,  exceed  eA'en  those  suggested  for  the  relief  of  epilepsy ; 
the  difference  between  the  two  diseases  being  that  one  generally  gets 
well  and  the  other  seldom  if  ever  does,  no  matter  what  drug  is  used. 

Now,  it  may  pertinently  be  said  in  this  connection  that  the  cure  of 
a  typical  chronic  case  of  chorea  without  the  use  of  drugs  is  a  fact  worthy 


CHOREA.  505 

of  record.  If  it  can  be  shown  that  correction  of  a  refractive  error  in  the 
e^-e,  or  the  relief  of  an  existing  "  insufhcieiicy  "  of  some  eye-muscle  by 
partial  tenotom}',  has  cured  most  obstinate  cases  of  chronic  chorea 
where  medication  and  all  other  lines  of  treatment  have  proved  of  no 
benefit,  the  value  of  the  method  must  be  recognized. 

I  have  seen  choreic  symptoms  disappear  in  several  instances  within 
a  week  or  two  when  an' existing  hyperopia  has  been  relieved  by  convex 
glasses,  with  the  frames  well  fitted  to  the  child,  so  that  each  pupil  is 
opposite  the  centre  of  the  glass.  It  is  not  enough  to  tie  a  pair  of  glasses 
with  frames  made  for  an  adult  onto  a  child's  head,  and  expect  that  com- 
fort to  the  child  will  follow  such  a  procedure.  Neither  is  it  right  to 
expect  that  glasses  are  all  that  is  demanded,  when  a  child  has  esophoria, 
exophoria,  or  hyperphoria,  in  addition  to  a  hyperopia  or  hyperopic 
astigmatism  or  refractive  errors  of  the  myopic  type.  The  case  reported 
on  page  499  was  one  of  the  worst  that  I  have  ever  encountered,  and  yet 
a  practical  recovery  ensued  when  the  muscles  of  the  eye  were  properly 
adjusted.  The  photographs  of  some  cases  of  chronic  chorea  published 
by  Dr.  Stevens  illustrate  more  forcibly  than  words  the  results  of  such 
treatment  when  skillfully  employed. 

Finally,  certain  precautions  are  to  be  exercised  in  reference  to  the 
child  by  its  parents  and  associates.  Study  should  be  interdicted, 
plenty  of  good  food  and  fresh  air  should  be  provided,  and  encouragement 
and  praise  should  be  freely  bestowed  as  aids  to  the  child  in  its  attempts 
to  conquer  the  choreic  habit. 

Anything  which  disturbs  and  annoys  the  patient  does  harm, — such, 
for  examyjle,  as  mimicrj^  confinement  to  the  house,  deprivation  from 
reasonable  pleasures,  etc. 

Arsenic  is  a  valuable  remedy,  in  a  large  proportion  of  cases. 
Fowler's  solution  may  be  given  to  a  child  after  eating,  beginning  with 
doses  of  three  drops  three  times  a  day,  and  gradually  increasing  the 
amount  by  the  addition  of  one  drop  each  day  until  the  patient  takes  ten 
drops  after  each  meal,  provided  that  nausea,  oedema  of  the  e3elids,  or 
other  toxical  effects  of  the  drug  do  not  appear.  I  do  not  believe  that 
arsenic  should  ever  be  pushed  to  the  poisoning  point,  in  spite  of  views 
advanced  to  the^  contrar^^  Iron,  cod-liver  oil,  and  quinine  may  be 
employed  in  a  combination  with  the  arsenic,  if  the  condition  of  the 
patient  is  anaemic,  or  if  good  results  do  not  follow  the  use  of  arsenic 
alone. 

The  judicious  use  of  chloral,  combined  with  digitalis,  may  be  of 
great  benefit  in  cases  where  persistent  insomnia  exists. 

Ice-bags  or  ether  spra}'  to  the  spine,  static  electricity  administered 
by  the  insulation  or  spark  methods,  and  general  galvanization  are  worthy 
of  a  trial  in  refractory  cases. 


n06  LECTURES  ON   NERVOUS   DISEASES. 

A  few  months  ago,  I  was  asked  by  Dr.  Stevens  to  meet  a  patient 
tliGU  under  his  care,  wliose  subsequent  recovery  possesses  great  clinical 
interest  in  tliis  connection.  1  give  the  details  of  this  case  as  the  patient 
stated  them  to  me  at  our  lirst  meeting  : — 

Mr.  C,  minister  of  the  gospel.  Mother  died  of  phthisis.  No  nervous  diseases  had 
existed  among  his  direct  ancestors,  or  in  remote  branches  of  his  familj-. 

About  twelve  years  before  this  interview,  his  family  had  noticed  frequent  facial 
contortions  which  he  was  unable  to  control.  Atrip  to  Europe,  and  parish  labors  in  a 
district  where  he  spent  most  of  his  time  in  a  carriage  and  wrote -but  little  in  his  study, 
prevented  its  increase  for  about  four  years.  He  then  became  the  pastor  of  a  church  and 
began  active  labor  in  his  study.  The  facial  contortions  grew  rapidly  more  aggravated  in 
character.  Every  feature  would  become  horribly  distorted ;  the  eyes  would  close,  the 
forehead  become  terribly  wrinkled,  and  the  nose  and  mouth  would  assume  attitudes 
which  no  one  could  possibly  imitate  by  volition,  and  which  it  is  difficult  to  describe.  The 
hour  of  retiring  was  particularly  dreaded,  because  the  facial  spasms  would  become  terribly 
persistent  and  severe  as  soon  as  the  eyes  were  closed  and  a  recumbent  posture  was 
assumed.  The  facial  contortions  were  always  least  severe  in  the  morning,  and  grew  more 
severe  as  the  day  progressed.     No  medicinal  treatment  had  ever  benefited  the  patient. 

An  examination  showed  hyperopia  of  a  high  degree,  esophoria  of  6°,  and  hyper- 
jihoria  of  right  eye  of  3°.  He  had  been  wearing  prisms  with  the  base  inward,  as  the 
suggestion  of  an  oculist. 

A  partial  tenotomy  was  first  performed  to  correct  the  hyperphoria.  The  facial 
spasms  ceaset^  ivithin  an  hour;  and  no  sign  of  chorea  was  observed  for  two  entire  days. 

On  the  third  day  a  very  slight  twitching  about  the  mouth  developed.  A  partial 
tenotomy  of  the  internal  rectus  of  the  left  eye  was  then  performed.  This  completely 
corrected  the  esophoria. 

Subsequent  to  the  second  operation,  the  patient  had  few,  if  any,  choreic  movements. 
He  stated  to  me  that  "unless  excited  his  face  remained  absolutely  quiet,"  and  that  for  the 
first  time  "he  had  that  day  been  able  to  attend  a  meeting  of  ministers  and  look  them  in 
the  face  without  facial  spasms  while  discussing  church  matters."  During  his  recital  of  his 
various  symptoms,  etc.,  to  me,  his  face  only  showed  one  very  slight  convulsive  movement. 
Thus,  in  less  than  one  week,  were  the  convulsive  spasms  of  his  face  almost  completely 
arrested  by  correcting  a  hyperopia  and  two  muscular  defects  associated  with  the  eye. 

Such  a  case  is  rarely  encountered.  The  patient  was  an  ndult.  The 
duration  had  exceeded  twelve  ^^enrs.  The  spasmodic  movements  were 
terribly  severe.  All  medication  had  failed  even  to  ameliorate  them. 
They  became  greatly  aggravated  as  soon  as  the  patient  was  compelled 
to  use  his  eyes  in  study  or  writing.  He  could  not  even  "  look  out  of  a 
car  window  "  without  being  thrown  into  a  most  distressing  state  ;  yet, 
in  spite  of  all  these  unf^ivorable  facts,  he  was  apparently  perfectl3'  well 
when  I  last  conversed  with  him. 

HYSTERIA. 

A  form  of  functional  disturbance  of  the  brain,  spinal  cord,  or  the 
sympathetic  nervous  system,  in  which  the  patient  gives  evidence  of 
'•an  abnormal    susceptibilit}'  to  external   impressions,  and  a  deficient 


HYSTERIA.  507 

power  of  the  will  to  restrain  its  manifestiitions,"  is  generallj'  termed 
"hysteria." 

It  is  encountered  chiefly  in  women.  In  the  male,  cases  are  some- 
what rare.*  Tlie  allied  conditions  known  as  "  catalepsy  "  and  "  hystero- 
epilepsy  "  will  be  discussed  also  under  this  head. 

Etiology. — A  ver}-  large  proportion  of  cases  of  this  type  develop 
symptoms  of  nervous  derangement  at  the  age  of  puberty  (twelfth  to 
twentieth  year).  Girls  reared  in  luxury  and  idleness,  especially  in  cities 
where  excitement  and  dissipation  are  cultivated,  suffer  more  than  those 
who  have  to  labor  and  those  who  enjoy  country  life.  Cases  of  genuine 
hysteria  are  sometimes  encountered  in  children  under  twelve  years  of 
age.  It  is  very  uncommon  for  hysteria  to  develop  after  the  age 
of  forty. 

Fsychical  influences  frequently  seem  to  excite  this  condition, 
especially  when  the  patient  is  predisposed  to  hysteria.  Among  such 
influences,  fear,  jealousy,  love,  disappointment,  anxiety,  care,  remorse, 
etc.,  are  more  liable  to  cause  hysteria  than  pleasurable  emotions  or  states 
of  mind. 

The  sexual  organs  are  liable  to  be  found  deranged  in  mnn}'  hysterical 
females.  Displacements  of  the  womb,  ulceration  of  the  cervix,  diseases 
of  the  ovaries  or  vagina,  scanty  menstruation,  or  irregularity  of  the 
periods,  leucorrhoea,  excessive  irritability  of  the  vulva  or  clitoris,  etc., 
may  be  often  detected  on  examination.  Self-pollution,  or  the  frequent 
occurrence  of  erotic  dreams,  in  females  is  not  uncommonly  met  with  in 
hysterical  subjects. 

Heredity  plays  an  important  role  in  hysteria.  A  phthisical  pi'e- 
disposition  is  extremely  common.  Again,  hysteria  may  be  directly 
transmitted,  or  it  may  alternate  with  epilepsy,  insanity,  sick-headaches, 
neuralgias,  chorea,  and  allied  conditions. 

In  this  connection,  my  remarks  concerning  eye-defects  and  muscular 
insufficiencies  in  the  orbit  when  discussing  epilepsy  and  chorea  might  be 
repeated  here.  Hysterical  subjects  are  almost  invariably  thus  affected, 
and  an  examination  of  the  eyes  and  the  eye-muscles  will  generally 
shed  light  upon  this  disease,  as  well  as  upon  its  allied  diseases.  The 
reader  is  referred  to  the  introductory  pages  of  this  section,  and  to  the 
views  advanced  respecting  the  causes  of  epilepsy  and  chorea. 

Finally,  imitation  has  been  known  to  cause  hysterical  attacks  in 
schools  and  convents.  In  such  cases  the  afflicted  probably  suffered  from 
one  or  several  of  the  predisposing  causes  mentioned,  the  attacks  being 
actually  developed  by  the  mental  impression  made  by  witnessing  an 
fittack  in  another. 

*  According  to  Briguet  about  fifty  males  were  attaclied  to  nine  hundred  and  fifty 
females. 


508 


LECTUEES   ON  NERVOUS  DISEASES. 


Morbid  Anatomy. — The  existence  of  any  organic  lesion  of  the  nerve- 
centres  may  be  considered  extremely  doubtful  in  any  case  of  hysteria, 
unless  some  other  symptoms  of  a  strongly  diagnostic  character  are 
detected.  I  have  on  my  case-book  the  records  of  one  case  of  liysteria 
where  a  calcified  state  of  the  falx  cerebri  and  the  adjacent  dura  was 
found  after  death.  A  few  cases  have  been  reported  where  other  organic 
changes  have  been  shown  to  have  existed,  and  to  have  unquestionably 
caused  the  hysterical  phenomena.  These  cases  must  be  regarded, 
however,  as  exceptional. 

All  authorities  seem  to  be  in  accord  in  the  statement  that  no 
pathology  of  hysteria  has,  as  yet,  been  recognized  as  proven. 

Symptoms. — These  are  so  varied  as  to  require  classification.  The 
following  table  will  bring  the  more  common  symptoms  of  hysteria 
prominently  before  the  mind  of  the  reader : — 


HYSTERICAL  PHENOMENA. 


Disturbances 

OF  THE 

Sp:nsory 
Apparatus. 


.    Hyper.es- 
T  II  E  s  1  A  . 

(Rarely  o  f 
the  whole 
body.)  It 
may  affect.. . 


2.    Anesthe- 
sia. 


One  entire  side. 

Occipital  region. 

The  back,  thorax,  or  abdominal  walls. 
1  Individual  joints. 
I  The  muscles. 
L  The  special  senses. 


r  Generally  of  left  side. 
May  affect  touch,  temperature  sensations  and  pain  {anal- 

fiesid).* 
Sensibility  may  remain  intact  in  spots  scattered  over  the 

anipsthetic  area. 
One  or  more  of  the  special  soises  may  be  lost  or  impaired. 
Joints  and  even  bones  may  be  deprived  of  sensation. 
_  Muscles  may  lose  their  electro-contractility. 


3.   Loss     OF 
Muscular 

Sense. 


Hvsterical  patients  sometimes  cannot  tell  if  thev  move  a 
limb,  or,  if  it  is  moved,  in  what  direction,  unless  they 
observe  it  with  their  eyes. 


4.  Neural,- 
GiAS(of  vari 
ous  nerves) . 


f  Coeeyihinia  (at  tip  of  spine). 
Sciiilicii  (in  lower  liml)). 
Intiri'oxtal  (most  often  near  seventh  rib). 
Lumbar  (in  small  of  back). 
Uracliialffia  (arm). 
riAKfofvari   ■!    Onial!/ia\nec]i). 

mis  iiArvPs'      I  C'''/)/('(?r/to  (headache).    This  is  a  very  common  symptom. 
J/ciiiicrdiiid  (coutined  to  one  side  of  head). 
Car<liith/iii  (i)ain  over  heart). 

Ocarialgia   (pain   over  ovaries).    This  is  a  valuable  diag- 
nostic sign. 
,  Machiulffia  (spinal  pain). 


Facial  spasm. 

Of  larynx,  pharynx,  and  CBSophagus  (the  so-called  "  globits 
lii/st'ericus'').  ' 

Paroxysms  of  uncontrollable  laughter. 

Paroxysms  of  uncontrollable  weeping  or  convulsive  cries 
(l):irkiiig,  howling,  etc.). 

Paroxysms  of  uncontrollable  hiccough  (due  to  diaphrag- 
matic spasm). 

IIysteri(:il  asthma  (due  to  bronchial  spasm). 

llystcrlial  yawning  (due  to  spasmodic  action  of  inspiratory 
muscles). 

Hysterical  cough  (due  to  irritation  of  the  laryngeal  nerves). 

*  Anaesthesia  of  the  larvnx  and  pharynx  is  a  very  common  symptom  of  hysteria.  In  many 
cases,  the  linger  or  a  proba'ng  may  be  introduced  into  the  larynx  without  exciting  coughing  or 
vomiting. 


j^^^tViI  z7oi|  ''^i^ 

Apparatus.    J     '^^  '^*'^^- 


HYSTERIA. 


509 


HYSTERICAL  PHENOMENA  {continued). 


B. 

Disturbances 

OF  THE  Motor 

Apparatus 

(continued). 


2.  Tonic  Hys- 
t  E  K  I  c  A  L. 

Spasms. 


C. 

VISCERAIj 

Disturbances. 


D. 

PSYCHICAt 

Disturbances. 


3.  GENEKAI4 

Convul- 
sions (hys- 
terical type). 


1.  Vaginismus  (often  preventing  sexual  intercourse). 

2.  Spasm  of  l)la(l(ler  and  rectum. 

3.  Goose-flesli  (due  to  erection  of  the  papillaR  of  the  derma). 

4.  Hysterical  contractures  of  the  limbs   (resulting  in  de- 

formity— usually  at  the  knee,  wrist,  fingers  and  toes). 
.5.  Torticollis  or  "  wry-neck." 

6.  Strabismus  or  "  cross-eye."    This  may  be  permanent  or 
transient. 


Constituting  "hystero-epilepsy."    These  may  be  partial  or 
general,  and  with  or  without  a  loss  of  consciousness). 


1.  Of  /ace.    May  exist  in  combination  with  hemiplegia  of 
the  same  side. 

2.  Of  eye.    Ptosis  and  alternating  strabismus  are  occasion- 
ally observed. 

.S.  Of  ORSophaijus  and  pharynx. 
4.  Of  larynx.    (Causing  "hysterical  aphonia.") 
.5.  Of  diaphraf/ni.    (The  voice  is  lost.   The  thorax  contracts 
p  (hiring  expiration  and  the  abdomen  rises.) 

i^RAL,Yhis  I  g    Of  Madder.    (Usually  accompanies  hysterical  hemiplegia 


Motor 


type). 


or  paraplegia  ) 

7.  Of  rectum.     (Accompanied  by  constipation,  tympanites 
and  rectal  anassthesia.) 

8.  Hemiplegia  or  parents.     (Usually  developing  after  ex- 
citement or  a  general  convulsion.) 

9.  Par(ipl(  f/ia  or  paresis.     (Usually  associated  with  para- 
ana'stliesia.) 

10.  Monoplegia  or  jiaresis.     (Generally  affects  arm  or  leg.) 

1.  Abnormal  respiration.   (Usually  increased  in  frequency.) 

2.  Abnormal  heart's  action.    (Palpitation  or  ana>niic  mui-mur.) 

3.  Impaired  digestive   functions.      (Capricious   appetite,   fasting,   vomiting, 

belching,  etc.) 

4.  Unnatural  craving  for  food.     (Boiilimia.) 

5.  Irregular  or  scanty  menstruation.    It  may  be  suppressed  {amenorrha;a). 
H.  Vicarious  menstruation  by  the  lungs  or  the  rectum. 

7.  Retention  of  urine.     (Requiring  the  regular  use  of  a  catheter.) 

8.  Abolition  of  sexual  excitement. 

9.  Increase  of  sexual  excitement.     (Nymphomania. ) 

C  Morbid  desire  for  sympathy  or  for  attracting  attention. 
Premonitory    J  Apathy  to  external' surroundings. 
manifestations  1  Obstinacy  to  all  influences  exerted  upon  the  patient. 

I.  Sudden  transition  from  gayety  to  sadness,  or  vice  vei'sa. 


Acute  manifes- 
tations. 


f  Hallucinations. 
LM 


Delirium. 

Ecstasy. 
"  'ania. 


Chronic  mani- 
festations. 


E. 

Vaso-motor 
Disorders. 


Melancholia. 

Ecstasy. 

Somnambulism  (usually  followed  by  convulsions,  if  the 

patient  is  awakened  while  out  of  bed). 
Nymphomania. 
Lethargv  or  stupor.     (Has  been  known  to  last  for  months 

without  any  interruption. ) 
,  Trance.   (It  niay  simulate  death  very  closely,  in  some  cases.) 

Elevation  of  temperature.     (Sometimes  preceded  by  a  chill.) 

Salivation.    (Probably  due  to  irritation  of  the  central  oi-igin  of  the  chorda 

tvmpani  nerves.) 
Polyuria.     (The  urine  being  very  light  in  color  and  deficient  in  salts.) 
OSdema.    (ITsually  appearing  suddenly  without  cause  and  disappearing  as 
L        suddenly.) 

After  a  perusal  of  this  table,  the  thought  may  occur  to  the  reader 
that  it  would  have  beeu  easier  to  mention  the  symptoms  which  do  not 
occur  in  h3'steria  tlian  those  that  may  be  encountered.  It  is  safe  to  say 
that  no  nervous  disease  (if  such  a  term  is  applicable  to  hysteria)  pre- 
sents a  greater  variety  of  forms,  or  may  more  closely  simulate  the  effects 
of  organic  lesions  of  the  nerve-centres.     The  diagnosis  of  hysteria  is 


510  LECTUEES   ON   NEKVOUS   DISEASES. 

almost  invariably  made  by  the  exclusion  of  more  serious  conditions 
which  the  symptoms  exhibited  by  the  patient  might  lead  a  ph^'sician  to 
strongly  suspect.  The  best  diagnosticians  are  sometimes  misled  by 
hysterical  subjects. 

Diagnosis. — To  the  practiced  eye,  there  are  certain  symptoms  in 
almost  every  case  of  hysteria  which  materially  aid  in  making  a  diagnosis ; 
although  it  is  ditticult  to  state  in  a  general  way  exactly  what  the  particu- 
lar points  in  a  given  case  may  be.  Certain  hints  may  be  given,  however, 
in  this  connection  with  advantage  to  tlie  reader. 

In  the  first  place,  the  historij  of  the  case  ma}'  aid  you.  If  the 
patient  has  from  childhood  l)een  very  impressionable  ;  if  she  has  been 
subject  to  periods  of  unnatural  excitement;  if  the  existence  of  similar 
conditions  in  the  family  can  be  traced ;  if  epilepsy,  insanity,  chorea, 
neurasthenia,  severe  and  recurrent  headaches,  or  neuralgias  have  ex- 
isted in  her  relatives  ;  if  anesthesia,  hyperesthesia,  painful  points,  or 
a  sense  of  compression  in  the  region  of  the  epigastrium  persist  after  the 
suspected  hysterical  paroxysm  has  passed  away,  and  if  transient  par- 
alyses have  appeared  at  any  time,  the  diagnosis  of  hysteria  is  more  than 
probable. 

Again,  whenever  the  paroxysm  assumes  the  convulsive  type,  the 
irregular  character  of  the  fit,  the  length  of  its  duration,  the  occurrence  of 
hiccough  or  of  laughing  or  weeping  after  the  convulsions  have  subsided, 
the  fact  that  the  convulsions  seldom  occur  at  night  or  when  removed 
from  the  possibility  of  sympathetic  attention,  and  the  passage  of  large 
quantities  of  pale,  clear  urine,  deficient  in  salts,  point  to  hysteria  or 
hystero-epileps3^  Energetic  pressure  upon  the  ovaries  may  also  modify- 
hysterical  convulsive  seizures,  while  in  epilepsy  this  test  is  negative  in 
its  results  (Charcot).  If  the  larynx  or  pharynx  is  anaesthetic,  so  that 
coughing  or  vomiting  cannot  be  induced  by  introducing  the  finger  or 
a  probang  after  the  attack,  hysteria  is  almost  positively  indicated. 

The  so-called  '' ylobiu^  hystericus,''^  the  sensation  of  a  ball  in  the 
throat,  the  absence  of  any  appreciable  rise  in  temperature  (when  taken 
in  the  rectum),  and  the  absence  of  albumen  or  casts  in  the  urine  point 
rather  to  hysterical  attacks  than  to  true  epilepsy,  uremic  convulsions, 
or  organic  lesions  of  the  nerve-centres. 

Hysterical  paralyses  may  generally  be  distinguished  from  the  paral- 
yses of  cerebral  or  spinal  lesions  by  the  gait  (page  165),  the  history  of 
its  onset,  the  absence  of  tremor,  the  testing  of  the  reflexes  (page  174), 
the  results  of  electrical  tests  (page  194),  and  the  history  of  the  case. 

The  diagnosis  from  trismus  or  true  tetanus  is  easily  made  by  the 
absence  of  a  history  of  some  injury  received,  the  method  of  extension  of 
the  convulsions,  the  fiicial  expression,  the  attitudes  assumed,  and  the 
typical  relaxation  and  termination  of  attacks  of  tetanus. 


HYSTEKO-EPILEPSY. 


511 


The  diagnostic  table  given  on  page  498  will  aid  the  reader  in  making 
a  discrimination  between  hysteria  and  other  diseases  wljich  it  may 
closely  resemble.  As  Hammond  very  aptly  remarks,  "careful  watching, 
with  thorough  skepticism,  will  either  result  in  detection,  or  in  the 
patient's  defeat  from  sheer  weariness." 

Let  us  now  pass  to  the  consideration  of  hystero-epilepsj',  catalepsy, 
and  ecstasy,  which  belong  to  the  lij^sterical  type  of  nervous  affections. 
The  prognosis  and  treatment  of  these  conditions  will  be  considered  later. 

HYSTERO-EPILEPSY. 
This  condition  is   characterized  by  peculiar  combinations  of  the 
symptoms  of  hysteria  and  epilepsy. 


Fig.  121.— Hystero-Epilepsy.     (From  a  photograph.    Case  of  C.  K.  Mills.) 

These  attacks  are  usually  preceded  by  some  of  the  prodromal  mani- 
festations of  hysteria. 

The  various  manifestations  of  this  form  of  attack  have  been  classified 
by  Richer  into  four  distinct  periods,  as  follow  :^ 

(1)  The  epileptoid  period. 

(2)  The  period  characterized  by  contortions. 

(3)  The  period  of  emotional  attitudes. 

(4)  The  period  of  delirium. 

The  symptoms  of  each  of  these  states  may  be  arranged  in  a  tabular 
form,  which  admits  of  a  contrasting  of  the  chief  peculiarities  of  each  by 
the  reader. 


512 


LECTURES   OX  NERVOUS  DISEASES. 


SYMPTOMS  OF  THE  FOUR  PERIODS  OF  HYSTERO-EPILEPSY. 


The  Fikst  orEpii.ep- 
Toii>  Period. 


1.  Premonitory  symptoms. 


2.  Convulsion,  characterized  by -. 


f  Tremor. 

'  Pupils  contracted. 
'  j   Uai)i(l  winking  of  the  lids. 
L  Rapid  respirations. 

'  Pupils  dilated. 

Face  pale  at  first  and  con- 
gested later. 

Loss  of  consciousness. 

Rigidity. 

Slow  bending  of  body  and 
twisting  of  head. 

Distortion  of  the  features. 

Pronation  of  the  hands. 

Adduction  and  slow  move- 
ments of  the  legs. 

Inversion  or  eversion  of  the 
feet. 

3.  Stage  of  secondary  rigidity  (patient  lies  in  a  fixed  attitude). 

■p„  ..  ,  ^  Unilateral, 
ir-arxiai  W'o„fl„ed  loonelimb 
^   *""     ,  S  Resembling  an  epi- 
General  |     ^^^^^^^  attack. 

f  Stertorous  breathing. 
-i   Frothing  at  mouth. 
t  Stupor. 

r  Incomplete  loss  of  conscious- 
ness. 

Extreme  opisthotonos. 

Piercing  shrieks. 

Forcible  and  rapid  movements 
of  the  limbs  (usually  of 
flexion  and  extension). 

Striking  uf  the  body. 

Tearing  of  the  clothing  and 
the  hair. 

Face  not  turgid. 

No  foaming  at  the  mouth. 
.  Duration,  o  to  10  minutes. 


4.  Stage  of  clonic  convulsion. 


_  5.  Stage  of  recovery. 


_        „  „  r  In  this  stage  the  following  s>  mptoms 

The  Second  or  Cox-  J      exist  and  the  movements  are  very  -> 

TORTiox  Period.       |     forcibly  made 


Fig   122. — An'othkr  Attitude  of  same  cask. 


The  Third  or  Period 
OF  Hallucinatioms. 


The  FotTRTtt  or 
Period  of  Delirium. 


[  Abolition  of  general  sensibility  to  touch,  pain,  or  temperature  usually 

exists. 
The  special  senses  may  be  in  abeyance. 
Various  forms  of  hallucination  exist. 
The  patient  may  answer  questions  uuconsciouslv. 
Various  expressions  are  uttered  and  certain  gestures  are  made  which 

indicate  the  form  of  hallucination  that  exists  (usually  that  of 

sight). 
Eyes  still  anfpsthetic. 
.  Pupils  may  be  contracted  or  dilated. 

The  patient  graduallv  passes  into  this  stage. 

Pupils  may  be  dilated. 

The  patient  wanders,  latighs.  weeps,  or  shows  mental  excitement  in 

other  wavs. 
The  patient  frequently  passes  large  quantities  of  urine. 


HYSTEKO-EPILEPSY. 


513 


The  second  unci  third  periods  described  are  of  especial  interest.  The 
contortions  observed  in  the  second  stage  are  often  horrible  to  witness. 
The  arms  and  legs  may  be  placed  in  the  most  revolting  of  attitudes. 


Fig  123.— Thiku  Attitude  of  same  case. 

In  the  third  stage,  the  expressions  of  the  patient  often  indicate  the 
greatest  alarm.  Hallucinations  of  sight  are  very  common  and  the 
patients  see  horrible  sights.  To  quote  from  Hammond,  they  "  hurl 
invectives  at  imaginar}'^  persons, — Scoundrels  I  robbers!  brigands!  Fire, 
fire!     Oh,  the  dogs,  they  bite  me!" 

Sometimes  it  becomes  necessaiy  to  feed  these  subjects  through  a 
tube  and  to  draw  the  urine  at  regular  intervals ;  because  the  pharynx 
and  the  bladder  are  occasional!}'  paralyzed  after  the  attacli. 


Fig  124. — Convulsion  of  Hystero-Epilepsy.     (From  a  photograph.    Case  of  C.  K.  Mills.) 

During  the  intervals  which  elapse  between  these  attacks  of  hystero- 
epilepsy,  many  of  the  sj'mptoms  enumerated  as  h^^sterical  develop  ;  such, 
for  example,  as  paralysis,  anaesthesia,  hypersesthesia,  and  diminution  of 
the  special  senses. 

33 


514  LECTURES  ON   NERVOUS   DISEASES. 


CATALEPSY. 

Catalepsy  can  be  classed  as  a  condition  closely  allied  to  hysteria. 
It  is  a  functional  neurosis,  with  no  recognized  pathology.  It  is  char- 
acterized by  attacks  of  partial  or  corni)lete  loss  of  consciousness,  which 
are  accompanied  by  a  peculiar  rigidity  of  the  muscles.  During  these 
attacks,  the  limbs  remain  in  any  position  in  which  they  chance  to  be  at 
the  onset,  unless  they  are  passively  moved  into  some  other  position  by 
outside  influence  or  until  the  limb  falls  from  exhaustion  of  the  muscles. 

Although  the  muscles  appear  tense  and  unyielding,  a  slight  amount 
of  force  suffices  to  came  them  to  yield  and  to  assume  any  posture  which 
an  investigator  may  desire.  They  will  then  remain  fixed  until  the  atti- 
tude is  again  changed  in  the  same  manner.  This  state  of  the  muscular 
system  has  been  termed  '■  waxy  flexibility." 

These  attacks  usually  begin  suddenly,  but  tliey  are  frequently  pre- 
ceded by  prodromal  symptoms,  as,  for  example,  by  yawning,  eructations, 


Fig.    125. — Case    of    Catalepsy,    exhibiting    the    Prolonged    Maintenance    of    an 
Artificially  Induced  Attitltde.     (From  an  original  sketch.) 

a  sense  of  pressure  in  the  head,  palpitation  of  the  heart,  vertigo,  a 
change  in  the  disposition,  etc. 

When  the  attack  develops,  the  patient  is  suddenly  rendered 
incapable  of  altering  the  position  in  which  he  or  she  may  be  at  tlie 
moment.  The  eyes  are  either  open  or  closed.  The  patient  may  occasion- 
ally understand  questions  and  yet  be  unable  to  respond  or  move.  The 
features  are  immobile,  and  the  whole  body  remains  as  if  suddenly  petrified. 

Sometimes  one  limb  is  affected  at  first,  but  the  rigidity  soon  extends 
OA'er  tlie  entire  bod}'.  The  respiration  is  often  slower  than  normal. 
The  heart's  action  is  regular.  The  power  of  swallowing  is  preserved. 
The  sensibilit}'^  of  the  skin  is  greath'  diminished  or  absolutely  lost.  The 
pupils  are  usually  dilated  and  respond  slowly  to  light.  Occasionalh',  the 
temperature  falls  below  the  normal  point  and  the  skin  is  pale  and  cold  to 
the  touch.  The  reflex  excitability  of  the  muscles  is  abolished  in  some  cases. 


CATALEPSY. 


515 


Either  sex  may  be  affected.  I  observed  with  greut  interest  in  1872 
an  attack  in  tlie  male,  which  came  under  my  notice  while  a  resident 
surgeon  in  Bellevue  Hospital.  The  details  of  this  case  are  given  in  full 
l)y  Hammond,  from  notes  furnished  him  by  my  friend,  Dr,  Earl3'.  The 
cataleptic  state  persisted  in  this  case  for  several  dajs.  The  temperature 
rose  to  100^  F. 

The  duration  of  cataleptic  attacks  varies  from  a  few  hours  to  several 
days.  They  generally  subside  with  sighing  and  a  desire  for  food.  A 
tendenc}'  to  recurrence  of  these  attacks  is  often  observed. 

Among  the  reported  causes  of  this  condition  the  following  may  be 
mentioned :  Pregnanc3',  mental  excitement,  grief,  anxiety,  mental 
disease,  hysteria,  chorea,  fevers,  narcosis  from  ether  or  chloroform,  and 
anaemia. 


Fig.  126. — A  Cataleptic  Patient  Supported  by  Head  and  Feet.     (From  a  sketch  made 

at  the  time.) 

These  patients  can  be  easily  nourished  if  food  is  made  to  pass  the 
fauces.  Death  may  be  simulated  during  cataleptic  attacks ;  but  the 
heart's  beat  and  respiration  can  be  easil}-  detected  l\y  a  careful  observer. 

Catalepsy  may  be  induced  in  "  hypnotic  "  subjects  by  suggesting  to 
their  minds  the  state  of  rigidity  of  the  muscles.  Charcot  has  supported 
a  patient  in  this  state  by  resting  the  nape  of  the  neck  and  the  ankles  upon 
the  backs  of  two  chairs  placed  about  five  feet  apart.  I  witnessed  a  sim- 
ilar condition  of  muscular  rigidity  in  a  cataleptic  during  m}'  connection 
with  Bellevue  Hospital  in  1872,  and  also  in  another  cataleptic  subject 
during  the  winter  of  1885.     (See  Fig.  126.) 


TREATMENT   OF   THE   HYSTEEICAL   STATES. 

Tlie  management  of  hysteria,  hystero-epilepsy,  and  catalepsy  will 
now  be  considered.  I  would  suggest,  in  the  first  place,  that  before 
any  medication  is  begun  a  thorough   search  be  made  for   eye-defects 


r)lG  LECTURES  ON  NERVOUS  DISEASES. 

which  have  been  discussed  in  the  introductory  pages  of  this  section, 
and  also  in  Section  II,  and  in  rehition  to  epilepsy  and  chorea.  In  case 
they  be  found,  they  should  be  corrected  l)y  olasses  or  i)artial  tenotomies. 
My  records  do  not  show  any  cases  of  hystero-epilepsy  and  catalepsy  in 
which  such  examinations  have  been  scientifically  made;  hence,  I  cannot 
tj;ive  any  personal  exi)eriences  in  reference  to  the  beneOcial  results  of 
this  treatment  except  in  hysteria.  Among  the  latter  class,  I  have 
observed  several  very  marked  examj^les,  where  a  close  relationship 
between  eye-strain  and  the  attacks  existed. 

I  could  quote  many  cases  from  my  case-book  if  I  deemed  it  neces- 
sary. The  records  in  all  go  to  show  that  eye-defect  existed,  and  that 
partial  tenotomies  gave  marked  relief  in  a  very  large  proportion  of  the 
whole  number  operated  upon  by  me. 

The  examination  of  the  eyes  of  hysterical  subjects  tends,  in  my 
experience,  to  lead  me  to  the  conclusion  that  a  defect  in  the  eye  or  its 
muscles  is  too  often  disregarded  or  unrecognized.  It  is  well  known  that 
heredity  plays  a  very  important  part  in  hysterical  cases,  as  well  as  in 
other  functional  diseases  ;  hence,  it  is  advisable  to  investigate  this  pos- 
sible factor  in  any  case  early,  and,  if  it  exists,  to  remedy  it  without  delay. 

In  hysterical  aneesthesia,  the  employment  of  the  secondary  coil  of  a 
faradaic  machine  by  means  of  the  wire  brush  often  acts  in  a  magical  way. 
Daily  applications  over  the  entire  area  of  anoesthesia  with  as  strong  a 
current  as  the  patient  can  comfortabl}'  bear  will  generally  cure  this 
symptom  in  a  sliort  time.  The  negative  pole  of  a  galvanic  liattery  may 
also  be  em[)loyed  with  decided  benefit  upon  the  ai'ea  of  amiesthesia. 

Hysterical  jyaralysis  yields  in  my  experience  most  quickly  to  heavy 
indirect  static  sparks.  Str3'chnia  and  i)hospliorus  are  valuable  aids  in 
eflfecting  a  rapid  recovery,  in  some  cases.  Persistent  daily  attempts  to 
use  the  limbs  should  be  urged  upon  the  patient. 

Hysterical  contractures  are  often  cured  by  static  sparks  and  passive 
motion.  The  galvanic  current  applied  through  the  positive  pole  to  the 
aflTected  muscles  (with  the  cathode  on  some  neutral  point — see  p.  186) 
often  gives  excellent  results.  I  prefer  "  stabile  "  applications  to  "  labile  " 
in  case  the  positive  pole  is  indicated.  Massage  may  be  employed  with 
marked  benefit  in  certain  forms  of  hysterical  contracture.  It  should  be 
practiced  daily  by  one  well  instructed  in  the  art ;  and  it  is  well  in  some 
cases  to  use  a  ftxradaic  current  for  from  thi-ee  to  five  minutes  dailj'  in 
connection  with  massage. 

Hysterical  paroxysms^  when  particularly  severe,  are  controlled  and 
often  entirely  relieved  by  the  inhalation  of  ether  or  chloroform.  These 
inhalations  may  be  repeated  as  often  as  the  symptoms  seem  to  warrant. 
It  is  generally  advisable  to  push  the  administration  of  ana?sthetics  at 
first  to  a  point  where  the  patient  is  rendered  insensible  by  them.     This 


TREATMENT   OF   THE   HYSTERICAL   STATES.  517 

rule  of  treatiueiit  M[)[)lies  with  equal  force  to  emotional  paroxysms  as 
well  as  to  those  where  spasm  is  the  prominent  feature  of  the  attack. 

Hysterical  voiniting  is  sometimes  obstinate.  Hydroc3anic  aci(l,sult- 
carl)ouate  of  bismuth,  blisters  over  the  epiuastrium,  strychnia,  ijhosphorus. 
and  cocaine  have  been  used  by  me  with  great  benefit  in  such  instances. 
The  valerianate  of  catieine  in  three-grain  doses,  repeated  in  a  half  hour  if 
necessar}',  has  been  highly  recommended  by  Paret,  Hammond,  and  others. 

According  to  most  authors,  the  so-called  ^'•'hysterical  state  "  may  be 
controlled  or  eradicated,  in  some  subjects,  by  long-continued  medication. 
While  I  am  inclined  to  believe  that  some  form  of  reflex  irritation  exists 
in  a  very  large  proportion  of  hysterical  subjects,  and  that  its  detection 
and  removal  constitutes  the  first  duty  of  a  physician,  still  I  am  not 
prepared  to  state  that  there  may  not  be  a  certain  proportion  of  this  class 
of  subjects  that  must  be  medicated  before  the  hjsterical  tendencies  are 
fully  ei'adicated.  I  do  not  believe,  however,  in  any  medicinal  specifics 
for  hj^steria. 

Among  the  remedies  which  have  been  suggested  for  the  relief  of 
these  cases,  the  following  maj'  be  cited  : — 

(1)  The  monobromide  of  camphor  may  be  given  either  in  an  emul- 
sion or  pill  in  doses  of  from  three  to  five  grains  every  hour  or  two  as  the 
symptoms  seem  to  indicate  (Hammond).  This  drug  seems  to  be  partic- 
ularly of  service  when  the  inhalation  of  ether  or  chloroform  is  contra- 
indicated  during  emotional  paroxysms  or  attacks  of  hysterical  convulsions. 

(2)  The  antispasviodics.  Musk,  A-alerian,  asafoetida,  and  the  vari- 
ous bromides  are  highly  recommended  by  authors  generally.  "Valerian 
is  best  administered  in  the  form  of  the  tincture,  extract,  Oj-  as  the 
valerianate  of  zinc.  The  nauseous  taste  of  the  latter  preparation  is 
Dest  overcome  by  giving  it  in  capsules. 

Castoreum  is  held  in  high  favor  by  some  authors.  It  is  somewhat 
expensive,  however,  and  is  not  alwa3S  procurable.  Ten  drops  of  the 
tincture  maj^  be  given  on  a  lump  of  sugar. 

The  bromides  of  sodium,  potassium,  calcium,  or  zinc  may  be  given 
in  large  doses  iintil  the  full  efiects  of  the  drug  are  obtained  in  cases 
wdiere  hyperaisthesia  or  mental  disturbances  are  prominent  manifesta- 
tions of  the  hysterical  state. 

(3)  The  mineral  tonics.  Arsenic  stands  at  the  head  of  this  list, 
in  my  opinion.  It  may  be  administered  in  pills  of  the  arsenate  of  iron, 
or  as  Fowler's  solution.  It  acts  well  when  anaemia  is  markedly  exhibited 
by  the  patient. 

Various  combinations  of  zinc,  copper,  silver  and  gold  have  been 
given  to  some  cases  with  apparent  benefit. 

(4)  The  nar'cotics.  This  class  of  drugs  has  been  quite  extensively 
employed  by  some  observers.     Opium  ma}'  be  administered   cautiously 


518  LECTURES   ON   NERVOUS   DISEASES. 

by  the  h^^podennic  syringe  or  hy  the  month  or  rcctiun.  Belladonna 
must  be  administered  with  extreme  eaution  ;  especially  if  its  active  prin- 
ciple (atropine)  is  employed.  It  sometimes  acts  well  when  hiccough 
exists,  or  when  convulsive  seizures  are  frequent. 

In  closing,  I  would  mention  certain  surgical  prockdures  which  have 
been  suggested  as  a  means  of  cure  of  hysteria  : — 

(1)  Cauterization  of  the  clitoris,  according  to  Friedreich,  often 
3'ields  good  results  in  hysteria. 

(2)  Removal  of  the  ovaries  is  now  frequently'  practiced  in  severe 
forms  of  h^'stero-epileps}'  (Battey's  operation). 

(3)  The  removal  of  the  clitoris  has  been  reported  as  having  led  to 
good  results. 

(4)  Partial  tenotomies  may  be  performed  upon  the  ocular  muscles, 
in  case  any  abnormal  tendency  to  deviation  of  the  visual  axes  inward, 
outward,  or  upward  can  be  detected  in  the  patient.  I  am  able  to  bear 
strong  testimony  to  the  efficacy  of  this  step  in  several  instances  in  which 
I  have  deemed  it  wise  to  operate. 

(5)  An  application  of  the  actual  cautery  may  be  made  to  the  spine 
and  the  nape  of  the  neck.  This  procedure,  in  my  experience,  has  given 
very  marked  relief  to  several  patients  of  the  hysterical  class.  Such 
applications  may  be  repeated  as  often  as  the  sj'mptoms  seem  to  demand 
them.  The  heated  platinuni-tii)  should  not  be  allowed  to  blister  or  burn 
the  skin.     It  should  simply  be  brushed  lightly  over  the  surface. 

Before  we  leave  the  subject  of  hysteria  and  its  allied  conditions 
(hystero-epilepsj^  and  catalepsy),  it  may  be  well  to  give  some  general 
directions  respecting  the  general  steps  which  should  be  taken  in  the 
management  of  such  a  case. 

It  is  very  essential,  in  the  first  place,  that  the  doctor  has  the  respect 
and  full  confidence  of  the  patient.  The  impression  made  upon  the  mind 
of  the  patient  by  the  personal  characteristics  of  her  medical  attendant 
has  often  a  great  deal  to  do  with  the  efficacy  of  the  steps  employed  for 
the  relief  of  the  symptoms.  Possibly  this  accounts  for  the  fact  that 
recoveries  have  occurred  under  lines  of  treatment  which  could  have 
had  little,  if  anything,  to  do  with  the  benefits  derived.  We  are  all 
too  apt  to  think  that  any  given  patient  recovers  in  consequence  of  some 
medicinal  agent  that  we  may  liave  administered,  when  perhaps  the  mind 
of  the  patient  has  simph'  been  fcn-cibly  influenced. 

In  the  second  place,  we  must  make  sucli  subjects  believe  that  their 
symptoms  are  perfectly  understood,  that  all  the  points  of  the  case  have 
been  thoroughly  noted  and  examined,  and  that  there  is  strong  reason  to 
hope  for  a  complete  recover}'.  Ridicule  or  the  implication  that  the 
symptoms  are  purely  imaginary  is  apt  to  destroy  the  ph3sician's 
influence  over  the  patient. 


NEURASTHENIA.  519 

Again,  the  use  of  the  term  "  hysteria  "  is  often  construed  by  the 
patient  or  her  friends  as  a  slur  upon  the  patient's  integrity  of  character; 
hence  it  is  well  to  avoid  it  in  discussing  the  case  outside  of  medical 
circles. 

Patients  of  this  class  generally  do  better  when  removed  from  the 
influence  of  sympathizing  friends,  or  surroundings  that  tend  to  recall  the 
original  exciting  cause  of  the  attacks.  Pleasant  and  cheerful  surround- 
ings, travel,  amusements  of  a  non-exciting  character,  etc.,  are  often  of 
great  advantage  to  such  patients.  A  married  woman  will  frequently 
improve  faster  when  taken  away  from  her  husband ;  and  it  is  often  well 
to  free  her  also  from  the  care  of  her  household  by  removing  her  from 
her  home. 

No  elfort  should  be  spared  to  improve  the  general  health  of  the 
patient.  Tonics,  good  hygiene,  regular  exercise  or  massage,  and  even 
the  so-called  "  rest  treatment "  (first  suggested  by  Mitchell)  may  be 
required  to  establish  this  end.  Some  cases  of  hj^steria  are  close  to  the 
border-lines  of  insanity,  and  must  be  treated  with  due  regard  to  their 
condition. 

Above  all,  do  not  fail  to  examine  for  all  possible  conditions  which 
may  exert  (through  reflex  irritation)  a  deleterious  influence  upon  the 
nervous  centres  of  the  patient.  Every  organ  in  the  body  should  be 
examined  before  this  question  be  decided  in  the  negative. 

Children  of  hysterical  mothers  should  be  brought  up  by  a  healthy 
wet-nurse,  and  given  every  possible  chance  to  grow  strong  and  robust. 

Ice-bags  or  a  pressure-pad  ma}'  be  placed  over  the  ovaries  (if  de- 
cidedly hypemesthetic)  with  benefit  to  some  patients.  The  use  of  cold 
.should  not  be  employed  for  more  than  an  hour  at  a  time  to  the  ovary. 
The  actual  cautery  or  blisters  have  been  suggested  as  a  substitute  for 
the  ice-bag,  since  both  tend  to  contract  the  blood-vessels  by  influencing 
the  vaso-motor  system  of  nerves. 

Static  insulation  (see  subsequent  section)  often  acts  charmingly 
with  hysterical  patients,  in  my  experience.  The  patient  should  be  very 
highly  charged  with  static  electricity  for  twenty  minutes  daily. 

NEURASTHENIA. 

By  the  term  neurasthenia  we  have  been  taught  to  include  all  mani- 
festations of  the  condition  commonl}^  known  as  '^'- nervous  exhaustion.'''' 

It  ma}^  be  manifested  in  a  variety  of  ways.  Its  symptoms  will 
depend  upon  the  type  which  exists — cerebral  exhaustion  or  spinal 
exhaustion — and  also  upon  special  idiosyncrasies  of  the  patient. 

Neurasthenia  has  been  brought,  in  my  opinion,  too  strongly  into 
prominence  as  an  independent  condition,  chiefly  through  the  writings  of 
Beard,  Mitchell,  Playfair^  and  Clark. 


520 


LECTURES   ON  NERVOUS   DISEASES. 


To  my  mind,  neurasthenia,  while  not  in  reality  a  disease  in  itself,  con- 
stitutes the  basis  of  many  of  the  functional  diseases  which  have  already' 
been  described  in  this  section  ;  hence,  much  that  has  been  said  in  rela- 
tion to  the  causation  of  epilepsy,  chorea,  hysteria,  hystero-epilepsy  and 
catalepsy  might  pertinently  be  repeated  here. 

Patients  probably  always  develop  the  neurasthenic  state,  to  a 
greater  or  less  degree,  prior  to  the  appearance  of  certain  symptoms 
which  are  characteristic  of  the  special  functional  diseases  already  dis- 
cussed. 

When  the  condition  of  neurasthenia  is  not  accompanied  or  followed 
by  convulsive  or  emotional  manifestations,  it  tends  to  manifest  its 
presence  by  many  other  morbid  phenomena.  These  have  been  classified 
by  Beard,  who,  in  various  monographs  which  he  issued  upon  this  sulyect 
prior  to  his  death,  has  minutely  described  the  abnormal  conditions  most 
frequently  encountered. 

Etiology. — The  more  common  evidences  of  functional  nervous 
derangements  which  we  so  often  encounter  to-day  (among  which  ma}' 
be  mentioned  sleeplessness,  muscular  twitchings,  nervous  dyspepsia, 
sick-headache,  haj^-fever,  morbid  fears,  sexual  debility,  melancholia, 
etc.)  were  uncommon,  and  are  still  so,  in  certain  climates  and  among 
certain  classes. 

The  reasons  why  functional  nervous  derangements  are  more  common 
now  than  of  old,  and  why  the  American  race  is  particularly  disposed  to 
them,  has  been  made  the  subject  of  much  scientific  thought  and  discussion. 
It  may  be  well  to  refer  to  a  few  of  the  causes  which  tend  to  promote 
nervous  debility.     Practical  suggestions  may  be  afforded  by  so  doing. 

Dryness  of  the  atmosphere  is  one  of  these  factors. — In  all  cold 
climates  the  humidity  of  the  atmosphere  is  less  than  in  the  warmer 
latitudes.  This  is  because  cold  air  condenses  moisture,  while  warm  air 
will  carry  a  large  amount  of  it  without  depositing  it  as  rain.  It  is  well 
known  that  dry  climates  predispose  to  nervous  excitability  by  absorbing 
the  natural  fluids  of  the  body.  Since  dry  air  is  a  poor  conductor  of 
electricity,  it  tends,  moreover,  to  cause  the  body  to  become  overcharged 
with  electricity,  and  thus  to  render  the  nervous  organization  abnormally 
susceptible  to  any  form  of  external  or  internal  irritation.  In  very  dry 
climates,  the  hair  becomes  stiff  and  brittle  on  account  of  a  want  of  the 
natural  moisture  and  oil.  Sparks  of  electricity  may  be  elicited  under 
such  circumstances  from  the  hair  by  drawing  a  comb  through  it,  and 
even  from  the  clothing  in  some  instances.  Men  and  animals  of  all  kinds 
become  fretful  and  irritable  when  exposed  for  an}-  length  of  time  to  dry, 
cold  winds,  so  often  encountered  in  the  Western  States.  The  vegetation 
is  frequently  shrivelled  and  parched  by  an  abstraction  of  its  moistui'e, 
and  its  vitality  is  quickly  destroyed. 


NEUEASTHENIA.  521 

Extremes  of  heat  and  cold  tend  to  cause  nervous  diseases. — In  the 
southern  climates,  and  in  the  small  islands  surrounded  by  salt  water 
which  are  known  as  health  resorts,  marked  extremes  of  temperature  are 
uncommon  ;  hence  we  find  less  susceptibilit}'  to  nervous  excitability  in 
the  inhabitants  of  these  climates,  when  contrasted  with  those  of  the 
Northern  States,  in  which  bitter  winters  are  followed  by  a  high  range  of 
temperature  during  the  summer  months.  The  freezing  blasts  of  winter 
compel  the  inhabitants  of  the  Northern  States  to  live  in-doors,  in  homes 
filled  with  a  dry  and  over-heated  atmosphere.  On  the  other  hand,  the 
heat  of  the  summer  months  does  not  encourage  out-of-door  exercises 
and  athletic  sports  as  a  popular  pastime.  Now,  in  England,  for  example, 
the  climate  is  more  equable  and  moist  than  in  America.  Athletic 
exercises  can  be  indulged  in  there  during  all  seasons  of  the  year,  and  are 
of  the  greatest  benefit  to  the  inhabitants.  While  I  am  glad  to  see  a 
growing  love  for  similar  sports  on  this  side  of  the  water,  the  peculiarities 
of  our  climate  Avill  never  permit  of  the  highest  development  and  general 
popularity  of  the  hunt,  tennis,  cricket,  foot-ball,  etc.,  with  the  masses. 
Thousands  may  attend  exhibitions  of  this  character,  but  those  who 
participate  must  of  necessity  be  few. 

The  heating  of  our  houses  is  an  innovation  upon  the  past. — Our 
grandfathers  brought  up  their  families  to  rel}^  on  food  and  exercise 
for  warmth.  In  the  Northern  States  the  log-fire  on  the  hearth  was 
the  only  way  of  keeping  warm  when  in-doors.  Now,  any  one  who 
has  had  experience  in  that  style  of  heating  will  accord  with  the  state- 
ment that  in  extremely  cold  weather  it  is  impossible  to  heat  a  room 
to  a  temperature  above  60°.  I  have  personally  known  water  to  freeze 
in  a  corner  of  a  room  in  New  England,  which  was  illumined  by  the 
blaze  of  a  roaring  fire.  The  bed-rooms  in  olden  times  were  cold,  and 
feather-beds  with  an  abundance  of  clothes  were  used  to  protect  the 
body  during  sleep.  The  hostess  of  olden  time  was  accustomed,  more- 
over, to  have  the  bed  warmed  for  the  guest  immediately  before  his 
retiring. 

In  some  parts  of  the  country  this  method  of  heating  is  still 
employed ;  but,  as  a  rule,  the  use  of  stoves,  furnaces,  and  steam  has 
superseded  the  hearth — much  to  the  injury  of  the  inhabitants.  Most  of 
us  are  now  baked  and  dried  all  winter  in  a  temperature  which  varies 
between  70°  and  80°.  We  shiver  when  a  slight  draught  enters  the  door 
or  window  casement.  We  pass  into  the  air  with  our  skin-circulation 
active,  our  pores  open,  and  our  bodies  lacking  the  proper  amount  of 
fluid,  since  it  has  been  abstracted  by  the  heat  of  our  houses.  Is  it  to  be 
wondered  at,  therefore,  that  an  extreme  of  cold  checks  our  perspiration, 
drives  the  blood  from  the  surface  to  our  lungs  and  digestive  viscera, 
whose  vessels  become  thus  over-filled,  and  causes  pneumonia,  pleurisy, 


522  LECTURES   ON   NERVOUS   DISEASES. 

liver  and  kidney  diseases,  and  tliousands  of  ills  to  the  nervous  organiza- 
tion whose  development  is  not  at  once  perceived? 

Oar  habits  of  eating  are  often  detrimental  to  health. — It  was  the 
custom  of  our  ancestors  of  a  century  ago,  if  inhabitants  of  a  northern 
climate,  to  eat  salt  pork  three  times  a  day  and  nearly  every  day  in  the 
year.  I  vividly  recall,  during  a  residence  of  four  years  in  New  England, 
the  dish  of  salt  pork  that  was  invariably  put  upon  the  table.  It  had  a 
constant  claim  to  recognition  as  much  as  its  companion,  the  castor,  A 
prominent  medical  author  humorously  remarked,  in  an  address  delivered 
some  years  ago  before  a  convention  of  doctors,  that  "  Pork,  like  the 
Indian,  flees  before  civilization."  He  says,  furthermore,  "  The  history 
of  the  rise  and  fall  of  pork  as  a  food  is  itself  instructive  in  relation  to 
the  first  effects  of  civilization  upon  the  nervous  system.  In  all  the  great 
cities  of  the  East  and  among  the  brain-working  classes  of  our  large  cities 
everywhere,  pork  in  all  its  varieties  and  preparations  has  taken  a 
subordinate  i)lace  among  the  meats  of  our  tables,  for  the  reason  that  the 
stomach  of  the  brain-worker  cannot  digest  it.  This  dethronement  of 
pork  has  had,  and  is  still  having,  a  disastrous  effect  upon  the  American 
people ;  for,  as  yet,  no  article  of  food  with  a  sufficient  amount  of  fat  has 
been  generally  substituted.  Fat  in  our  dietaries  is  one  of  the  most 
imperative  hygienic  needs  of  our  time,  which  has  come  to  be  felt,  both 
instinctivel}'  and  rationally,  and  which,  on  all  hands,  we  are  tr3ing  to 
meet  by  the  use  of  cream,  cod-liver  oil,  eggs,  fish,  and  the  fats  of  fresh 
meat." 

It  has  been  my  custom  for  years  to  allow  babies  suffering  from 
nervous  debility  to  chew  upon  a  well-cooked  rind  of  salt  pork.  I  believe 
that  this  form  of  food  must  of  necessit}^  always  be  the  main  article  of 
animal  food  for  the  community  at  large. 

I  would  call  attention,  in  the  second  place,  to  a  habit  which  is  com- 
mon among  brain-worlcers,  viz.,  of  eating  irregularly  and  too  rapidly,  and 
the  drinking  of  large  quantities  of  fluid  during  their  meals.  It  needs  no 
argument  to  prove  that  both  conduce  to  destroy  or  impair  the  powers 
of  digestion.  Who  would  think  of  jilacing  a  bucket  of  water  by  the  side 
of  a  horse  every  time  it  was  fed.  If  food  is  properly  masticated,  the 
saliva  should  suffice  for  all  lubrication  necessary  to  the  act  of  swallowing. 

Our  systems  of  education  may  conduce  toioard,  ill  health. — It  is  a  well- 
recognized  fact  among  scientific  medical  men  that  a  defective  construc- 
tion of  the  eye  is  present  from  birth  in  quite  a  large  percentage  of 
children.  As  long  as  the  child  and  its  parents  are  ignorant  of  such  a 
defect,  or  until  the  defect  is  remedied  by  glasses  properl}-  adjusted  to  the 
e3'e,  serious  harm  may  ))e  done  to  the  nervous  system  l)y  the  strain  to 
which  that  important  organ  is  constantly  subjected.  Most  children  in 
the  larger  cities  are  now  compelled  to  spend  from  five  to  six  hours  each 


NEUEASTHENIA.  523 

a  clay,  for  ten  months  in  the  3'ear,  in  a  school-room ;  and  to  use  their 
eyes  as  well  as  their  intellect  after  school  hours  in  preparation  for  the 
exercises  of  the  ensuing  da}'.  It  is  not  infrequent  for  medical  men  to 
encounter  adults  who  have  been  rendered  victims  of  countless  nervous 
maladies  b}'  defects  in  vision  which  have  never  been  corrected  by  the 
use  of  glasses. 

A  far-sighted  child  becomes  easily  fatigued  when  attempts  at  read- 
ing, writing,  or  stud}'  are  made ;  hence  he  quickly  develops  tastes  lor 
out-of-door  amusements  in  which  he  usually  excels.  Children  of  this 
type  are  often  punished  for  a  willful  neglect  of  their  studies,  whenever 
impaired  vision  from  a  tired  ciliary  muscle  renders  it  impossible  for 
them  to  accomplish  the  allotted  task.  On  the  other  hand,  near-sighted 
children  cannot  indulge  in  out-of-door  sports  because  their  vision  either 
prevents  it  entirely  or  makes  them  awkward  in  their  attempts  ;  hence 
they  are  generally  fond  of  reading,  and  are  too  often  regarded  as  preco- 
cious beyond  their  years.  The  steady  increase  in  the  functional  dis- 
orders of  the  eye,  which  is  proven  by  all  of  the  carefully  prepared 
statistics,  may  be  attributed,  in  part  at  least,  to  the  neglect  of  parents 
in  having  the  eyes  of  children  examined  by  a  competent  oculist  before 
they  are  sent  regularly  to  school. 

One  of  the  most  frequent  symptoms  of  nervous  exhaustion  in  adults 
is  a  weak  condition  which  manifests  itself  in  a  sense  of  pain  and  weariness 
whenever  the  eyes  are  used.     This  condition  is  known  as  "•  asthenopia." 

Our  hrjgienic  surroundings  should  be  conducive  to  health. — A  very 
large  proportion  of  the  patients  who  are  referred  to  me  for  advice 
respecting  functional  nervous  maladies  owe  their  troubles  in  part  to 
defective  hygiene.  Most  of  the  large  cities  are  imperfectly  sewered,  and 
few  dwellings  are  built  with  a  proper  regard  for  the  requirements  of 
health.  The  business  offices  in  cities  are  often  so  dark  as  to  be  con- 
stantly damp  and  filled  with  the  vapors  arising  from  the  consumption  of 
illuminating  gas.  They  are,  as  a  rule,  over-heated,  ill-ventilated,  deprived 
of  sunlight,  and  often  imperfectly  protected  against  sewer  gases.  This 
statement  is  true  also  of  all  of  our  stores,  and  of  some  of  our  dwellings. 
It  is  one  of  the  natural  results  of  economy  of  space  entailed  by  the  high 
value  of  land. 

While  it  is  difficult  to  obA'iate  this  element  of  disease  in  cities,  it  is 
well  to  impress  the  minds  of  laymen  with  the  fact  that  sunny  bed-rooms, 
perfect  ventilation,  and  pure  air  are  of  vital  importance  to  health.  Large 
cities  are  not  the  best  places  for  people  of  moderate  means  to  live  in. 
Their  business  otlices  may  be  in  the  city,  but  their  homes  from  choice 
should  not  be.  A  person  may  breathe  impure  air  for  a  few  hours  each 
day  with  comparative  impunity,  if  he  can  have  its  effects  counteracted  by 
pure  country  air  during  his  hours  of  rest  and  the  Sabbath. 


524 


LECTURES   ON  NERVOUS  DISEASES. 


Alcohol,  tobacco,  and  other  stimulants  are  often  used  to  excess. — 
There  is  a  deeply  rooted  opinion  aniono;  some  of  tlie  laity,  and  medical 
profession  also,  that  tobacco  and  alcohol  are  the  most  i)roniinent  factors 
in  producing  the  steady  increase  of  nervous  maladies  which  is  generally 
recognized  as  existing.  It  is  not  m^-  intention  to  discuss  the  question 
of  temperance  here  from  a  social  or  moral  aspect.  What  remarks  I  feel 
myself  obliged  to  make  on  this  point  are  of  a  purely  medical  character. 

From  information  gathered  l)y  personal  observation  and  careful 
inquiry  and  research,  I  am  convinced  that  our  ancestors  were  fully  as 
indulgent  in  the  consumption  of  tobacco  and  alcohol  as  are  those  of  the 
present  generation,  and  probabl3^  very  much  more  so.  Many  of  our 
grandfathers  and  grandmothers  can  be  shown  to  have  used  both  alcohol 
and  tobacco  to  excess,  without  developing  an}-  of  the  functional  nervous 
derangements  of  to-day.  Ladies  of  the  Southern  States  formerh*  indulged 
to  excess  in  the  habit  of  snuti-dipping.  Men  and  women  were  habit- 
ually addicted  to  the  use  of  snuti"  as  a  stimulant  to  the  mucous  mem- 
brane of  the  nose,  during  the  epochs  when  it  was  fixshionable.  The  open 
sideboard  is  certainly  less  common  to-day  in  private  residences  than  in 
the  past.  People  do  not  now,  as  a  rule,  take  their  "  night-cap  "  before 
retiring  ;  but  it  was  once  the  universal  custom.  Bulwer  happily  remarks 
that  "  it  requires  a  very  strong  constitution  to  dissipate." 

Now,  it  is  very  common  for  me  to  have  nervous  patients  tell  me 
that  the}'  have  been  obliged  for  years  before  they  sought  my  advice  to 
discontinue  the  use  of  alcohol  and  tobacco.  Some  of  my  patients  are 
unable  to  drink  tea  or  cotlee ;  others  are  abnormally  susceptible  to 
stimulating  narcotics,  such  as  opium  ;  while  a  few  are  unable  to  tolerate 
many  of  the  drugs  which  they  could  previously  use  with  impunity.  On 
the  other  hand,  I  am  satisfied  that  nervous  exhaustion  is  a  cause  of 
confirmed  inebriety  in  many  instances. 

It  seems  to  me  that  we  are  forced  by  what  has  thus  far  been  said, 
without  further  illustration,  to  the  following  conclusions:  (1)  that  the 
tendency  of  the  age  is  toward  nervous  excitabilit}' and  debilit^y  ;  (2)  that 
the  brain-workers  (in  contradistinction  to  the  muscle-workers)  are  more 
susceptible  to  external  and  internal  disturbances  than  in  past  genera- 
tions ;  (3)  that  many  of  the  factors  enumerated  can  be  justly  included 
among  the  elements  which  have  produced  this  result;  (4)  that  the 
American  race  is  particularly  prone  to  nervous  derangements;  and  (5) 
that  we  are  ourselves  partly  responsible  for  the  modifications  which 
have  taken  place  in  the  constitutional  vigor  of  man  as  civilization  has 
progressed. 

Before  I  pass  to  the  consideration  of  the  more  prominent  symptoms 
of  functional  nervous  derangements,  I  may  state  that  the  premature 
decay  of  the  teeth  has  been  brought  forward  I)}'  Beard  as  one  of  the  most 


NEUKASTHENIA.  525 

strikinir  evidences  of  the  steady  increase  of  the  constitutional  impair- 
ment wliich  has  followed  our  present  methods  of  living.  It  is  common 
to  hear  dentists  account  for  this  fact  on  various  grounds,  among  which 
may  be  mentioned  the  use  of  acids,  the  eating  of  sweet  things  to  excess, 
a  lack  of  scrupulous  cleanliness,  and  the  elimination  of  such  foods  as 
require  thorough  mastication.  AVhile  1  do  not  deny  that  there  may  be 
a  justification  for  these  views,  still  I  would  draw  the  attention  of  my 
readers  to  the  fact  that  the  teeth  of  the  negro  race,  of  the  Indian,  and  of 
all  semi-barbarian  tribes  are  proverbially  perfect.  This  is  the  case  in 
spite  of  the  circumstance  that  they  are  extremely  fond  of  sweets.  It  is 
also  true  that  they  seldom  if  ever  clean  their  teeth,  and  that  they  never 
sutler  from  cavities  except  in  old  age.  Neither  are  the  teeth  of  these 
races  nor  of  animals  irregular  ;  yet  how  common  are  such  deformities 
among  the  descendants  of  intellectual  and  refined  ancestors  1  We  should 
remember  in  this  connection  that  the  nutrition  of  all  parts  of  our  frame 
is  controlled  by  the  nerves.  Is  it  not  rational,  therefore,  to  regard  im- 
perfect bone  nutrition  and  development  as  a  result,  in  some  instances  at 
least,  of  an  impairment  of  the  nervous  functions  ? 

Morbid  Anatomy. — In  the  early  stages  no  pathological  lesions  can 
be  detected  in  man}-  neurasthenic  subjects.  Later  on,  sclerosis  may 
possibly  be  developed  in  exceptional  instances,  and  many  other  varieties 
of  structural  change.  Doubtless,  these  al)normal  conditions  are  either 
induced  or  hastened  by  a  state  of  nervous  debilit}' ;  but  thej'  cannot  be 
said  to  be  more  than  mere  coincidences. 

Symptoms. — Neurasthenia  may  aflect  the  cells  of  the  brain  or  of  the 
spinal  cord  separately.  Hence  we  are  forced  to  clinically  recognize  two 
types  of  neurasthenia, — the  cerebral  and  spinal. 

Cerebral  neurasthenia  {brain  exhaudion)  may  be  indicated, according 
to  Beard,  by  one  or  more  of  tlie  following  sj-mptoms:  Tenderness  of  the 
scalp;  pains  in  the  head;  fleeting  neuralgias;  sleeplessness;  vertigo;  a 
tenderness  and  pallor  of  the  gums;  abnormal  sensitiveness  of  the  teeth; 
blanching  of  the  hair;  flushings  of  the  face;  dilatation  of  the  pupils; 
idiosjmcrasies  in  regard  to  food  and  external  irritation  ;  mental  depres- 
sion and  melancholia;  defects  in  memory;  a  morbid  craving  for  alcohol; 
a  decrease  in  intellectual  capacity;  a  buzzing  or  ringing  in  the  ears; 
specks  before  the  A'ision;  abnormal  and  imaginary  impressions  of  taste 
or  smell;  morbid  fears  of  various  kinds;  sick-headache;  dryness  of  the 
skin  and  the  mucous  surfaces;  weakness  of  the  muscles;  numbness  in 
the  limbs;  thickness  of  speech;  and  mental  excitability,  irascibility'  or 
loss  of  emotional  control. 

These  symptoms,  in  manj'  cases,  are  but  the  manifestations  of  weak- 
ness. The  electric  batteries  of  the  brain  (the  minute  organs  known  as 
the  "brain-cells'')  are  feeble  or  uncertain  in  their  action.      They  are 


526 


LECTURES   OX  NERVOUS  DISEASES. 


incapable  of  performing  tlie  oflices  for  wliicli  they  were  created.  They 
are  not  diseased  (in  a  medical  sense),  but  they  are  weak  and  liable  to 
become  so  sooner  or  later.  I  have  known  sufferers  of  this  type  to  be 
precipitated  into  a  condition  approaching  incurability  by  mental  alarm; 
excited,  in  some  instances,  by  an  opinion  of  an  unfavorable  kind  made 
by  physicians  respecting  a  prospect  of  recover^'.  Again,  it  is  well  known 
that  insanit}'^  may  arise  as  a  consequence  of  the  loss  of  sleep  often  experi- 
enced by  these  subjects,  and  by  "brooding  over  their  symptoms"  whose 
signihcance  they  fail  to  properly  understand.  I  recall  several  cases 
where  a  patient  was  with  dilKcult}'  convinced  that  some  special  type  of 
malady  was  not  about  to  attack  him,  because  in  reading  a  medical  work 
his  attention  had  been  called  to  the  significance  of  some  special  symptom, 
which  he  was  sure  he  had  personally  experienced.  If  medical  students 
who  possess  vivid  imaginations  can  become  (as  they  often  do)  victims  to 
imaginary  diseases  whose  symptoms  they  have  been  studying,  is  it  to  be 
wondered  at  that  the  weak  and  highly-organized  sutterers  from  neuras- 
thenia are  especially  prone  to  become  impressed  by  this  form  of 
delusion  ? 

Spinal  neurasthenia  {spinal  exhaustion)  signifies  an  exhausted  state 
of  the  cells  which  help  to  form  the  spinal  cord.  The  cord  itself,  although 
only  about  the  size  of  an  ordinary  lead-pencil,  is  composed  of  millions  of 
nerve-cells  and  distinct  Inindles  of  nerves.  Some  of  these  nerves  pass 
through  it  to  reach  the  brain  above,  while  others  become  united  to  the 
spinal  cells  and  pass  no  further.  The  cells  of  both  the  brain  and  spinal 
cord  are  practically  electric  batteries  ;  and  the  nerve  fibres  are  the  wires 
by  which  they  are  connected  with  the  different  organs  of  the  body,  the 
muscles,  skin,  joints,  and  viscera.  This  wonderfully  constructed  organ  is 
under  the  control  of  the  brain  ;  but  is  capable  of  exerting,  under  certain 
circumstances,  a  control  over  all  acts,  which  are  termed  "  reflex  acts" 
because  they  are  to  a  greater  or  less  extent  independent  of  the  will. 

Now,  when  the  cells  of  the  spinal  cord  become  exhausted,  the  symp- 
toms produced  differ  markedl}^  from  those  already  mentioned  as  indica- 
tive of  brain-exhaustion.  Among  its  chief  manifestations,  may  be 
mentioned  the  following :  A  general  tenderness  of  the  skin  to  touch  or 
pressure;  tenderness  along  the  spine  or  over  certain  limited  portions  of 
the  spine;  irritability  of  the  breasts,  ovaries,  and  the  womb  in  females; 
fleeting  pains  of  a  neuralgic  type  in  A-arious  parts  of  the  body;  an 
extremely  rapid  or  slow  pulse,  which  fluctuates  widely  during  periods 
of  excitement  or  fatigue;  attacks  of  palpitation  of  the  heart;  dryness 
of  the  skin,  or  in  many  cases  tlie  reverse;  excessive  perspiration  of  the 
hands  and  feet;  sudden  startings  on  going  to  sleep;  muscular  twitchings 
in  one  muscle  or  a  group  of  muscles;  chilliness  and  creeping  sensations 
along  the  spine;    numbness  or  abnormal  sensations  of  heat  in  the  skin 


NEUKASTHENIA.  527 

of  the  body  or  limbs;  itching  of  the  skin;  eruptions  upon  the  skin, 
chiefly  of  the  type  of  eczema;  frequent  gaping,  yawning  or  stretching ; 
frequent  seminal  emissions ;  weakness  of  the  bladder  and  rectum ;  and 
disturbances  of  the  digestive  functions. 

The  distinction  between  cerebral  and  spinal  neurasthenia,  which  has 
been  stated  by  man}'  observers  to  exist,  cannot  be  made  in  each  and 
every  case,  because  various  combinations  of  the  symptoms  of  the  two 
are  often  encountered  in  the  same  individual.  A  prominent  author  upon 
this  type  of  diseases  very  aptly  compares  the  nervous  system  of  man  to 
certain  mountainous  regions, — since  it  causes  so  many  echoes  and  rever- 
berations. He  says,  "  An  irritation  at  one  point  may  be  transferred  to 
any  other  point,  following  the  paths  of  least  resistance,  and  making  itself 
felt  in  those  parts  that  are  least  able  to  resist  molecular  disturbances. 
Thus,  for  example,  seminal  emissions  and  spermatorrhoea,  when  they 
arise  through  abuse  or  through  spinal-cord  disease,  almost  uniformly 
react  on  the  brain, — robbing  the  sufferer  of  courage  and  manliness, 
exciting  various  phases  of  morbid  fear  (of  which  I  shall  speak),  with 
aversion  of  the  eyes  and  countenance. " 

I  have  known  a  decayed  tooth  to  cause  persistent  earache,  and  in 
one  case  to  cause  the  corresponding  ej-ebrow  to  become  white.  In  male 
children,  a  tight  foreskin  not  infrequently  creates  sufficient  irritation  of 
the  sexual  organs  to  induce  spasms  or  paral^^sis  of  the  lower  limbs  by 
an  indirect  effect  upon  the  spinal  cord.  I  have  frequently  cured  patients 
who  have  come  to  me  for  relief  from  persistent  and  excruciating  attacks 
of  neuralgia,  b}'  a  correction  of  some  defect  in  their  eyes.  The  extrac- 
tion of  a  tooth  has  frequently,  in  my  experience,  relieved  facial  and 
orbital  neuralgia. 

It  may  be  well  to  consider  a  few  of  the  more  prominent  manifesta- 
tions of  nervous  exhaustion  separately.  Among  these,  sleeplessness,  a 
defect  in  vision  known  as  asthenopia,  sexual  weakness,  headache,  an 
unnatural  dryness  of  the  skin  and  mucous  surfaces  or  profuse  sweating 
of  the  hands,  and  morbid  fears  or  melancholia,  deserve  special  mention. 

Insomnia. — Sleeplessness  may  assume  different  forms.  Some  of 
those  afflicted  have  difficulty  in  getting  asleep ;  some  awake  after  a  few 
hours  of  slumber  and  remain  so  until  daylight ;  a  few  find  themselves 
overpowered  with  a  desire  for  sleep  during  their  working  hours,  when 
their  business  will  not  admit  of  it,  and  at  night  cannot  obtain  sleep 
except  under  narcotics.  I  have  had  patients  who  have  told  me  that 
they  spent  most  of  their  nights  for  years  in  writing  to  friends, 
riding  in  the  horse-cars,  or  walking  the  streets  for  amusement  because 
they  could  not  sleep.  It  is  safe  to  assert  that  persistent  insomnia, 
extending  over  a  period  of  weeks  or  months,  indicates  in  most  cases 
a  persistent   cause  of  neurasthenia  or  organic  disease  of  some  kind. 


528  LECTUKES   ON   NEEVOUS   DISEASES. 

In  patients  w'.u)  have  passed  the  age  of  fifty,  or  in  younger  persons 
who  haA-e  indulgcil  to  excess  in  alcohol,  it  is  often  due  to  a  type 
of  kidney  disease,  to  detect  whicli  repeated  examinations  of  the  urine 
are  required.  Tliis  form  of  trouble  is  known  as  the  "  granular "  or 
"contracted  kidney  ;"  and  insomnia,  frequently  combined  with  headache, 
is  one  of  its  most  prominent  symptoms.  Obstinate  sleeplessness  is  the 
cause  of  many  a  suicide,  too  often  the  starting  point  of  the  opium  and 
chloral  hal)it,  and  surely  the  destroyer.  I  would  caution  my  readers 
a-^ainst  allowing  this  symptom  to  remain  uncontrolled  in  a  patient  for 
Lny  length  of  time ;  to  avoid  the  use  of  all  forms  of  narcotics  as  long  as 
possible";  and  to  keep  the  patient  from  acquiring  a  habit  of  using  them 
without  medical  authority.  The  chains  of  intemperance  are  but  silken 
threads  when  compared  to  those  of  the  opium  or  chloral  habit. 

Adhem2na.— This  type  of  defective  vision  cannot  be  relieved  by 
ordinary  glasses ;  nor  does  it  respond  quickly  to  the  customary  sugges- 
tions of  gymnastics,  horseback-riding,  etc.  It  is  due,  as  a  rule,  to  a 
defective  equilibrium  in  the  muscles  which  control  the  movements  of 
the  eyeballs,  and  it  manifests  itself  chiefly  as  a  sense  of  extreme  weariness 
when  the  eyes  are  steadily  employed  for  short  periods  of  time.  It  is  an 
Indication  of  neurasthenia,  and  is  of  great  diagnostic  value.  In  many 
cases  it  becomes  necessary  to  partially  divide  the  tendons  of  the  stronger 
muscles  of  the  eye,  in  order  to  relieve  the  weaker  ones  of  a  strain.  I 
have  seen  patients  who  could  not  sew  for  five  minutes  at  a  time  from  this 
cause,  and  others  who  would  be  made  sick  by  attending  a  theatre,  picture 
o-allery,  or  other  i)laces  of  amusement.  The  reader  is  referred  to  pre- 
ceding pages,  which  deal  with  this  subject  at  greater  length. 

Headache. — Many  attacks  of  this  character  are  undoubtedly  to  be 
attributed  to  imprudences  in  eating,  exposure,  or  fatigue.  But  I  believe 
that  most  of  those  who  are  periodically  afflicte:!  in  this  way  owe  their 
suffering  to  a  lack  of  tone  in  the  muscular  coat  of  the  blood-vessels  of 
the  brain,  consequent  upon  some  of  the  causes  of  neurasthenia  mentioned. 
I  have  seen  a.  large  number  of  instances  where  the  eyes  ^vere  the  cat(se  of 
such  headaches,  and  where  the  adaptation  of  glasses  has  brought  imme- 
diate relief.  The  medical  profession  are  rapidly  becoming  enlightened 
upon  this  fruitful  cause  of  pain.  It  is  well  also  to  examine  the  urine 
when  persistent  or  periodical  headache  occurs,  as  it  may  be  a  symptom 
of  kidney-disease.  Some  neurologists  believe  that  the  so-called  "  sick- 
headaches  "  are  to  be  regarded  as  but  a  modified  form  of  that  condition 
which  produces  epilepsy.  This  condition  will  be  considered  separately 
in  subsequent  pages. 

Dryness  or  Unnatural  Moisture  of  the  Sinn. — Some  nervous  patients 
suffer  from  an  unnatural  dryness  of  the  skin,  the  throat,  and  the  nose. 
They  are  also  liable  to  experience  dyspeptic  symptoms  at  the  same  time, 


NEURASTHENIA.  529 

which  are  probably  clue  to  similar  changes  in  the  lining  of  the  stomach. 
This  dryness  may  be  accompanied  also  by  an  itching  of  the  affected  parts 
or  an  attack  of  eczema.  A  burning  sensation  is  sometimes  produced.  I 
was  once  consulted  by  a  patient  who  had  been  in  the  habit  of  encasing 
himself  in  flannel  and  putting  on  flannel  stockings  before  he  retired 
for  years,  in  order  to  overcome  a  sense  of  burning  in  the  skin  which 
followed  the  contact  of  cotton  or  linen  with  any  part  of  his  body.  I 
recall  a  case  where  the  feet  were  once  frost-bitten,  and  the  patient  has 
never  been  able  since  to  walk  upon  a  carpeted  floor  on  account  of  a 
burning  sensation  which  immediately  follows,  lie  takes  oflT  his  shoes  as 
the  last  step  before  retiring. 

On  the  other  hand,  many  patients  afflicted  with  neurasthenia  suffer 
from  a  profuse  sweating  of  the  palms  of  the  hands.  This  is  accom- 
panied in  some  instances  by  a  flushing  and  redness  of  the  fece,  neck, 
and  ears.     The  nails  may  become  unnaturally  soft  or  brittle. 

Morbid  Fears. — This  peculiar  manifestation  of  nervous  exhaustion 
may  assume  one  of  several  types.  Attempts  at  classificatioi^  of  these 
morbid  fears  have  been  made  by  some  authors,  such  as  fear  of  lightning, 
of  places,  man  and  society,  solitude,  accident,  etc.,  and  special  names 
have  been  applied  by  them  to  each  of  these  types.  Fears  of  this  kind 
may  be  present  without  any  other  manifestation  of  mental  impairment. 
They  are  usually  uncontrollable,  in  spite  of  the  feet  that  the  patient  may 
exhibit  a  knowledge  that  they  are  groundless  and  absurd.  The}'  seem  to 
take  full  possession  of  a  being,  and  to  cause  mental  torture  of  an  extreme 
kind. 

Finally,  melancholia  is  not  an  infrequent  symptom  of  neurasthenia. 
It  may  be  accompanied  by  paroxysms  of  laughing,  weeping,  and 
liysterical  phenomena. 

Prognosis. — I  have  never  observed  a  case  of  neurasthenia  where 
death  has  occurred,  save  through  some  intercurrent  disease ;  and  I  doubt 
if  such  an  occurrence  has  ever  been  noted  by  a  competent  observer.  I 
have,  however,  seen  organic  disease  develop  in  the  brain  and  spinal  cord 
(apparently  as  a  sequel  to  the  neurasthenic  state)  in  several  instances. 
Melancholia,  delusions  of  various  kinds,  and  even  mania  have  been 
known  to  develop  in  subjects  who  had  previously  suffered  from  symp- 
toms of  nervous  exhaustion.  I  am  not  inclined  to  believe  that  these 
cases  are  extremely  uncommon.  Quite  a  large  proportion  of  insane 
subjects  give  a  history  which  leads  to  a  different  conclusion  than  that 
given  by  most  authoi's. 

A  very  large  proportion  of  neurasthenic  cases  drag  out  a  miserable 
existence  for  years;  become  hopeless  invalids;  and  eventually  die  of 
some  intercurrent  disease.  It  is  a  daily  experience  with  me  to  encounter 
both  males  and  females  who  are  totally  unfitted  for  the  active  duties  of 

34 


530  LECTURES   ON  NERVOUS   DISEASES. 

life  from  neurasthenia.  To  many  of  them  the  possibility  of  death  would 
be  robbed  of  its  terrors,  because  life  has  ceased  to  be  a  source  of  comfort 
or  of  usefulness. 

Treatment. — In  this  class  of  cases,  my  experience  has  convinced  me 
that  "e^-e-strain  "  constitutes  one  of  the  most  important  factors  in  tbe 
causation  of  the  symptoms,  and  that  the  detection  and  relief  of  the  defect 
which  exists  in  any  individual  case  is  of  the  greatest  importance.  I 
could  quote  case  after  case,  if  space  would  permit,  to  prove  this  asser- 
tion. One  of  the  most  remarkable  instances  of  this  kind  which  ever 
came  under  ray  personal  observation  may  be  Avorthy  of  record  here : — 

Case  I.  Cerebral  Neurasthenia,   Oastralgia,  Persistent   Tremor,  etc. — Mrs.  ,  aged 

forty-three.  Her  father  and  mother  died  of  [ihthisis,  as  well  as  several  blood  relatives.  Has 
two  children;  was  "very  nervous"  as  a  child.  For  the  yiast  sixteen  years  has  been  more 
or  less  of  an  invalid.  For  some  years  the  patient  has  not  been  able  to  spend  her  evenings 
with  her  family  or  to  see  company.  She  reads  without  fatigue,  has  suffered  but  little  with 
headaches,  and  has  never  had  marked  asthenopic  symptoms.  She  had  suffered  greatly 
for  some  years  with  recurring  attacks  of  gastralgia,  a  loss  of  emotional  control,  severe 
palpitation  of  the  heart,  and  an  inability  to  endure  physical  exertion  or  any  form  of 
excitement.     Has  always  been  regular  in  menstruation. 

When  I  first  saw  the  patient,  she  trembled  violently,  had  moist  palms,  and  could  not 
without  great  effort  control  her  emotions.  Her  eyes  were  constantly  averted  while  in 
conversation,  being  generally  directed  toward  the  floor.  Her  voice  was  feeble  and  tremu- 
lous, and  at  times  scarcely  audible.  Under  any  excitement,  she  would  experience  a 
choking  sensation.  During  one  interview  in  my  office,  she  was  so  attacked,  and  suffered 
like  a  person  in  the  height  of  a  paroxysm  of  asthma. 

An  examination  of  her  eyes  under  atropine  showed : — 
Emmetropia. 

EsopJioria  of  a  high  degree  (6°). 
Power  of  abduction  4°;  of  adduction,  28°. 

Daily  applications  of  static  insulation  gave  her  but  little  relief;  although  they  were 
persisted  in  for  some  weeks.  Prismatic  glasses  annoyed  her  and  yielded  negative  results. 
Her  tremor  and  emotional  excitability  persisted,  and  her  condition  remained  practicallj' 
unchanged.  Finally,  she  consented  to  allow  me  to  perform  partial  tenotomy  upon  her 
internal  recti  muscles.  Within  twenty-four  hours,  her  trembling  ceased  and  has  not 
returned.  In  less  than  two  weeks  she  was  able  to  attend  places  of  amusement,  entertain 
her  friends  and  perform  all  the  duties  of  life  as  well  as  when  a  girl.  She  has  remained 
absolutely  free  from  attacks  of  gastralgia  and  cardiac  palpitation  since  the  last  operation 
(nearly  two  years  ago),  and  looks  at  least  ten  years  younger  than  when  I  first  saw  her. 

This  case  illustrates  admirabl}'  the  following  points:  (1)  that  no 
asthenopic  symptoms  had  ever  existed,  in  spite  of  the  eye-defect;  (2)  that 
prisms  failed  to  relieve  the  patient;  and  (3)  that  tenotomy  cured  her  of 
tremor,  gastralgia, and  cardiac  palpitation. besides  a  host  of  other  neuras- 
thenic sj^mptoms.  It  is  needless  to  add  that  the  patient  had  tried 
medicinal  agents  without  number  during  the  many  years  that  she  had 
been  an  invalid. 


NEURASTHENIA.  531 

Another  equally  striking  case  of  cerebral  neurasthenia  is  illustrated 
in  the  following  history : — 

Case  II.  Cerebral  Neurasthenia,  Constant  Pain  in  the  Head  of  Five  Years'  Duration, 
Asthenopia,  etc. — Female,  unmarried,  aged  twenty-one  years. 

Famihj  History. — Maternal  aunt  and  five  paternal  relatives  died  of  phthisis ;  two 
cousins  had  chronic  chorea. 

Eye-defects. — Patient  had  hyperopia  (latent)  of  1.25  D.  and  exophoria  (manifest)  of  2°. 
A  latent  hyperphoria  of  2°  was  subsequently  discovered. 

This  young  lady  was  brought  into  my  office  by  two  assistants,  who  were  obliged  to 
carry  her  from  the  carriage.  For  several  years  she  had  been  carried  daily  from  her  room 
to  the  library  of  her  father's  house,  and,  after  reclining  in  a  chair  for  a  few  hours,  she 
would  be  again  carried  to  her  bed-room.  She  could  manage  with  difficulty  to  walk  slowly 
across  a  room.  She  had  not  been  able  to  write,  read,  sew,  or  see  her  most  intimate 
friends  for  five  years  on  account  of  a  constant  pain  in  her  head,  which  was  rendered 
intolerable  by  any  use  of  the  eyes  or  excitement.  Her  symptoms  began  while  at 
boarding-school,  from  which  she  was  removed  to  her  home  in  a  recumbent  posture  and  by 
easy  stages. 

I  used  static  electricity  upon  this  patient  for  some  weeks  with  a  slight  improvement 
in  her  power  of  walking,  but  no  relief  to  her  head.  I  then  persuaded  her  to  consent  to  a 
relief  (by  partial  tenotomies)  of  her  abnormal  eye-tension.  Tenotomies  were  then  per- 
formed upon  her  left  superior  rectus  and  both  externi  within  the  space  of  two  weeks. 
From  that  date  her  improvement  was  very  rapid.  She  was  sent  home  a  few  weeks  later 
practically  cured. 

A  letter  from  her  physician,  lately  received  by  me,  says : — 

"  Your  patient  is  the  wonder  of  this  region.  She  rivals  the  '  Jersey  Lily '  in  her  feats 
of  walking." 

Before  this  patient  was  sent  home  she  ascended  and  descended  five  flights  of  stairs 
daily,  and  averaged  over  a  mile's  walk  each  day  without  a  companion  to  assist  her. 

In  case  the  eye  be  found  to  be  entirely  free  from  abnormalities  of 
refraction  or  accommodation,  and  the  ocular  muscles  to  be  normal,  I 
would  advise  rest  as  a  valuable  step  toward  a  cure.  The  plan  first 
suggested  by  Dr.  S.  Weir  Mitchell  (now  generall}-  known  as  the  "  rest- 
cure  ")  has  proven  of  great  value  in  some  of  ni}'  cases.  It  consists  of 
perfect  isolation,  a  prolonged  confinement  to  bed,  and  a  total  cessation 
of  bodily  or  mental  pursuits,  combined  with  regular  and  sj^stematic 
feeding,  massage,  and  electrical  applications.  It  is  especiallj^  adapted 
for  females  ;  but,  in  a  modified  form,  is  useful  in  male  subjects. 

With  males,  it  is  usually  well  to  advise  early  a  total  withdrawal 
from  business  for  a  time,  and  retirement  to  some  quiet  place  where  out- 
of-door  sports  can  be  indulged  in.  I  seldom  advise  travel,  because  it 
involves  too  much  excitement. 

Sleeplessness  may  usually  be  controlled  by  a  judicious  use  of  the 
bromides,  some  preparations  of  valerian,  chloral,  hjoscj-amus,  conium, 
or  opium.  I  seldom  employ  any  drug,  however,  for  the  relief  of  this 
symptom  until  I  have  thoroughly  cauterized  the  back  of  the  neck  (over 


532 


LECTUKES   ON   NERVOUS   DISEASES. 


the  point  of  entnuice  of  the  vertebral  arteries)  with  the  white-hot 
phitiuuni  tip.     Such  an  a})[)lication  is  often  immediate  in  its  etiects. 

Sweating  of  the  hands  and  feet  is  generally  relieved  by  atropine  and 
friction  of  the  parts  after  bathing  them  in  very  hot  water. 

Disturbances  of  the  digestive  functions  are  often  greatl}'  benefited 
by  a  prolonged  use  of  hot-water  drinking  (see  p.  248)  and  the  adminis- 
tration of  tonics.  Stimulants  may  be  given  in  some  cases  directl}'  after 
eating.  In  occasional  instances  I  am  compelled  to  restrict  patients  for 
a  time  exclusively  to  a  milk  diet. 

Static  electricity,  by  the  spark  method,  the  static  breeze,  or  simple 

insulation  often  acts  as  a  great  aid  in  the  cure  of  these  cases.     General 

faradization  or  general  galvanization  are  excellent  methods  of  emploj'ing 

electricity  upon  these  subjects,  in  case  a  static  machine  is  not  attainable,  or 

as  a  substitute  for  static  applications  when  the  patient  fails  to  respond  to 

its  influence. 

MIGRAINE — SICK-HEADACHE — MEGRIM. 

This  distressing  condition  is  characterized  by  paroxysmal  attacks 
of  pain  in  the  head  (usually  unilateral,  but  not  always  so),  accompanied 
b}' nausea,  eructations  of  gas  from  the  stomach,  and  vomiting.  Between 
the  paroxysms,  the  patient  generally  enjoj's  more  or  less  perfect  health 
and  is  free  from  pain. 

There  is  perhaps  no  form  of  pain  that  is  more  commonly  encountered 
by  the  physician  than  this  ;  unless  it  be  "  neuralgia  "  in  the  common 
acceptation  of  that  term.  Sufferers  from  sick-headaches  are  to  be  found 
in  ever}'  large  cit}'  and  countr}^  town,  especiall}'  among  the  brain-workers 
in  contra-distinction  from  the  muscle-workers.  No  clime  or  atmospheric 
condition  seems  to  confer  immunity  from  the  attacks  to  those  who  are 
congenitally  predisposed  to  them. 

I  approach  the  discussion  of  this  subject  with  more  than  ordinary 
interest,  because  for  nearly  thirty  years  I  was  personally  a  victim  to  the 
most  severe  form  of  these  attacks.  Within  the  past  ten  j'ears,  I  have 
treated  a  very  large  number  of  these  cases  with  the  most  satisfactory 
results ;  hence,  my  convictions  are  strong  in  reference  to  their  causation 
and  their  treatment. 

Etiology. — Migraine  runs  in  families.  Hereditarj^  predisposition  is 
perhaps  more  strongly  marked  in  this  affection  than  in  most  of  tlie 
so-called  functional  nervous  maladies.  In  all  of  this  class  such  a  pre- 
disposition is  very  marked,  and  particularly  so  in  migraine. 

Most  authorities  classify'  migraine  under  the  "  vaso-motor  neuroses ;" 
but,  in  the  light  of  my  own  observations  in  this  special  field,  I  prefer  to 
discuss  it  under  the  head  of  functional  nervous  diseases,  because  I 
believe  that  reflex  irritation  of  the  oculo-neural  type  lies  at  the  bottom 
of  the  attacks. 


MIGKAINE — SICK-HEADACHE — MEGKIM.  533 

It  is  quite  remarkable  how  often  the  family  history  of  this  class  ot 
patients  points  to  a  tubercular  jwediajmaition.  It  is,  in  my  experience, 
very  rare  to  find  typical  attacks  of  migraine  in  a  male  or  female  who  has 
not  had  some  relatives  die  of  phthisis. 

For  many  years  I  have  taught  in  my  lectures  that  I  had  yet  to  meet 
a  case  of  typical  migraine  in  which  an  examination  of  the  eyes  or  the 
eye-muscles  Avould  not  show  the  existence  of  a  marked  error.  All 
observations  to  date  confirm  me  in  this  view.  Latent  hyperopia  is 
an  extremely  common  cause  of  reflex  disturbance  in  these  cases ;  and 
esophoria  or  hyperpho?'ia  (p.  143)  are  not  infrequentlj^  found. 

No  one  in  the  profession,  as  far  as  my  information  goes,  has  ever  kept 
such  careful  records  of  the  condition  of  the  eye  and  its  muscles  in  de- 
scendants of  "  consumptive  "  ancestry  as  has  my  friend,  Dr.  G.  T.  Stevens. 
His  investigations  in  this  particular  direction  have  been  noted  carefully 
in  several  thousand  patients.  The^^  go  to  confirm  my  own  researches  in 
the  conclusion  that  a  hyperopic  eye  exists  in  an  extremel}^  large  percent- 
age of  these  subjects,  and  that  ocular  insufficiency  is  also  very  common 
among  them. 

To  avoid  repetition,  I  would  refer  the  reader  to  some  pertinent 
remarks  upon  the  generally  accepted  views  respecting  the  causes  of 
sick-headache  which  I  have  made  in  the  second  section  of  this  work 
(p.  127). 

The  age  varies  at  which  patients  experience  their  first  attack.  Gen- 
erally they  develop  during  childhood,  provided  the  occupation  of  the 
child  requires  much  eye-work,  as  in  the  case  of  educational  pursuits.  If 
they  begin  after  the  twenty-fifth  year,  I  generally  am  led  to  suspect  some 
intercurrent  disease  in  addition  to  "'eye-strain." 

Symptoms. — Attacks  of  sick-headache  are  always  paroxj^smal  and 
peculiarly  "  explosive  "  in  character.  The}^  come  without  known  cause, 
as  do  epileptic  seizures ;  although  all  persons  so  afflicted,  as  well  as 
their  doctor,  usually  think  that  they  know  the  particular  exciting  cause 
of  each  paroxysm.     (See  p.  128.) 

Premonitory  symptoms,  as  a  rule,  warn  the  patient  of  the  approach 
of  an  attack.  They  awake  with  a  peculiar  "heavy  feeling"  in  the  head, 
or  a  sense  of  languor,  or  a  disinclination  to  eat,  or  to  smoke  (if  addicted 
to  tobacco).  They  are  often  constipated,  and  feel  a  peculiar  aversion  to 
mental  ettbrt  or  to  gayety.  Sudden  movements  of  the  head  or  body  are 
often  followed  by  pain  in  the  head.  Stooping  is  liable  to  produce 
unpleasant  sensations.  They  are  apt  to  yawn  frequently,  and  eructations 
are  not  uncommon.  In  rare  instances,  these  attacks  are  preceded  bj'  a 
marked  buoyancy  of  spirits  on  the  preceding  day. 

As  the  day  progresses,  pain  of  a  decided  character  begins  to  be  felt 
in  the  head.     It  may  be  unilateral  or  bilateral.     If  unilateral,  the  left  or 


534 


LECTUKES   ON  NERVOUS  DISEASES. 


the  right  side  :ire  equiill}'  apt  to  be  the  scut  of  i)aiii.  The  spccia,!  senses 
become  Jibnormally  iicute.  The  temi)onil  arteries  are  swollen  on  the 
artected  side  and  feel  like  whip-eords  beneath  the  skin.  The  patient 
begins  to  experience  pulsations  within  the  head,  which  send  shooting 
pains  with  them  of  a  severe  character.  The  region  of  the  stomach  often 
feels  unpleasantly,  as  if  distended  with  gas.  Light  becomes  painful,  and 
the  eye  of  the  affected  side  gradually  changes  in  its  appearance.  It  is 
usually  dull,  retracted,  and  not  widely  opened.  The  pupil  may  be 
slightly  dilated. 

The  seat  of  pain  may  be  at  first  in  the  occipital  region  or  over 
the  forehead  or  temple ;  but  it  tends  to  spread  gradually  over  the 
affected  side  as  the  paroxism  increases  in  severity.  The  cervical 
region  of  the  spine  is  apt  to  be  more  or  less  affected  with  an  aching 
sensation. 

Toward  the  close  of  the  day  the  patient  is  obliged  to  give  np  busi- 
ness and  retire  to  absolute  quiet  and  a  dimly-lighted  room,  provided  the 
attack  is  a  severe  and  typical  one.  The  pain  becomes  more  and  more 
intense  until  it  culminates  in  vomiting.  This  often  closes  the  attack  and 
the  patient  falls  into  a  heav}'  sleep  closel}^  resembling  that  wdiich  follows 
an  epileptic  seizure.  Several  fits  of  vomiting  are  generally  experienced, 
accompanied  by  retching,  sweating,  pallor  and  extreme  physical  prostra- 
tion, before  entire  relief  from  pain  comes. 

No  one  who  has  never  experienced  a  scA'-ere  attack  of  this  kind  can 
conceive  of  the  torture  which  such  a  patient  endures.  It  deprives  him 
of  all  power  of  performing  the  simplest  mental  processes  and  takes  awa}' 
the  ability  to  endure  suffering.  In  addition,  the  patient  is  harassed  bj' 
all  forms  of  visual  disturbances,  even  when  the  lids  are  closed.  Such 
patients  ma}'  be  rendered  partiall}'  or  totally  blind  during  the  attack. 
The  hearing  and  smell  are  so  acute  as  to  detect  things  which  would 
otherwise  be  unnoticed,  and  to  cause  them  to  suffer  acutely  in  conse- 
quence of  such  perceptions.  Bright  zigzag  lines  of  light  often  seem  to 
flit  across  the  vision  ;  or  luminous  spots  may  appear,  which  grow  in  size 
and  brilliancy  till  they  become  intolerable.  Sensation  may  be  abolished 
in  some  well-defined  area  of  the  skin. 

The  frequency  of  the  paroxysms  varies  in  different  individuals. 
Some  have  them  once  a  week,  others  once  a  montii,  others  much  less 
frequently. 

Between  the  attacks  the  patient  usually  feels  perfectly  well  and 
generally  suffers  from  no  nervous  symptoms.  There  are  exceptions  to 
this  rule,  however,  which  are  well  illustrated  in  the  few  cases  cited. 
These  are  taken  from  my  own  records.  They  represent  but  a  small 
fraction  of  similar  cases  which  I  am  constantly  observing  in  my  practical 
office  work. 


Without  atropine 


MIGKAINE — SICK-HEADACHE — MEGRIM.  535 

Case  I.  Inherited  Sick-headache,  Vertigo,  Loss  of  Emotional  Control,  etc. — Mr. , 

aged  twenty-eight;  has  had  severe  headaches  at  least  once  each  week  since  the  age  of  six. 
Consum[ition  very  frequent  in  his  maternal  ancestry  and  immediate  relatives.  Has  suffered 
with  dijilopia  at  times  ;  especially  when  fatigued  by  the  use  of  the  eyes  for  near-work.  Has 
lately  had  a  marked  increase  of  the  headache.  The  attacks  are  excruciatingly  severe 
and  almost  constant.  Has  tried  almost  every  known  drug,  but  has  found  all  more 
or  less  unsatisfactory.  Within  the  three  months  preceding  the  examination  of  the  eyes 
has  had,  in  addition  to  the  headache,  "extreme  nervousness,"  with  a  loss  of  emotional 
control,  attacks  of  vertigo,  which  have  been  distressing,  and  an  inability  to  use  the  eyes 
steadily  for  any  length  of  time  without  great  fatigue.  Has  used  a  +  1.00  D.  glass  at 
times  for  reading. 

Examination  of  the  eyes  shows  : — 

r  0.  D.  V ffi 

0  S  V     .  ....  ^0 

Binoc.  V f  f 

External  insufficiency  (esophoria) 7° 

Adduction 20° 

Abduction     .    .• 4° 

Visual  field normal. 

(_  Reading  power :  No.  1  type  read  easily  by  -|-  1.50  at  ten  inches. 

^  0.  D.  3?_o_ made  fa  by  +  3.00 

0.   S.  t2_o. made  |§  by  -f  3.00 

Binoc.  fo'V made  |^  by  +  3.00 

External  insufficiency  5°,  but  totally  relieved  by  -|-  3.00  glasses, 

without  prisms. 
Beading  power :  test  type,  No.  1,  read  with  ease  with  -\-  4.00. 

Ordered  -(-  1.75  glasses  for  each  eye,  in  spectacle-frames  ;  these  to  be  worn  constantly, 
for  both  distant  and  near  vision. 

The  correction  of  this  ocular  defect  made  a  complete  cure.  The  patient  did  not  have 
a  headache  for  over  eight  months,  and  all  the  nervous  symptoms  disappeared  immediately. 
During  the  past  five  years,  the  attacks  of  headache  have  not  exceeded  two  a  year.  They 
invariably  follow  excessive  mental  effort  and  a  protracted  use  of  the  eyes.  This  case 
illustrates  well  the  acuteness  of  vision  which  existed  before  the  use  of  atropine,  in  spite  of 
a  high  degree  of  hyperopia. 

Case  II.  Headache,  Mental  Depression,  and  Insomnia. — Mr.  ,  aged  forty-nine ; 

lawyer.  Phthisis  common  among  maternal  ancestry.  Has  had  more  or  less  headache, 
but  no  periodical  attacks  of  migraine.  Has  begun  to  suffer  for  the  past  two  years  with 
extreme  headaches,  insomnia,  inability  to  use  the  eyes,  great  mental  depression,  and  vertigo. 
Has  never  required  glasses  even  to  read. 

Examination  of  the  eyes  shoivs .- — 

A  "  manifest"  myopia  of —  0.75  existed  before  atropine  was  used. 

Hyperopia  under  atropine  corrected  by  +  1-50. 

External  insufficiency  (esophoria)  of  1°. 

Adduction,  10°;  abduction,  5°. 

Marked  ciliary  spasm  (as  shown  by  the  effects  of  atropine). 

An  uncontrollable  trembling  of  the  head,  and  severe  pain  at  the  occiput  invariably 
occurred  during  the  testing  of  the  eyes  for  insufficiency,  before  atropine  was  used. 


With  atropine 


536  LECTURES  ON  NEEVOUS  DISEASES. 

This  was  one  of  the  most  interesting  cases  I  liave  ever  seen.  Any 
attempt  at  convergence  of  the  eyes  gave  intense  occipital  pain  and  a 
shaking  of  the  liead  which  would  dislodge  the  spectacle-frame.  Although 
he  exhibited,  under  atropine,  a  latent  hyperopia  of  a  marked  degree,  he  was 
apparently  myopic  before  its  use,  on  account  of  an  existing  ciliary  spasm. 
Tiie  total  muscular  power  of  adduction  and  abduction  was  extremely  low. 

The  use  of  atropine  arrested  all  the  reflex  nervous  phenomena  in 
this  subject  at  once.  He  was  kept  under  its  influence  for  a  week ;  was 
given  +  1.50  glasses  for  reading  and  all  near-work.  By  the  use  of  pris- 
matic, daily  exercise  for  the  muscles,  he  recovered  the  normal  power  of 
convergence  and  divergence  in  about  three  weeks.  In  this  case,  static 
sparks  were  administered  daily  to  the  occiput  and  cervical  region  of  the 
spine  for  several  weeks,  as  it  gave  the  patient  a  great  sense  of  relief  in 
the  head.  Although  all  pain  had  ceased  from  the  first  administration  of 
atropine,  a  sense  of  "  fullness  in  the  head  "  remained,  which  was  over- 
come entirely  by  the  static  spark  and  ergot. 

Case  III.  Hysteria  and  Morbid  Fears,  associated  with  Headache. — Mrs. ,  aged 

twenty -seven  ;  wife  and  mother  of  two  children.  Has  a  well-marked  phthisical  ancestry. 
Patient  has  had  scrofulous  joint-disease.  Prior  to  the  examination  she  had  been  growing 
hysterical,  with  a  tendency  to  cry  constantly.  Has  had  repeated  "  sinking  feelings."  Has 
an  aversion  to  crowds,  and  morbid  fears.  Suffers  greatly  from  sick-headaches.  Has  had 
amenorrhoea  for  many  years  at  intervals. 

Examination  of  the  eyes  shows: — 

Without  atropine,  0.  D.  V.=|^ with  atropine,  i%  imperfect. 

0.  S.  V.:=f^ "  "         |§         " 

.  "  "      Esophoria,     4°. 

"      Adduction,  12°. 
"  "      Abduction,    6°. 

Hyperopic  astigmatism  of  a  high  degree  (+  l-SO)  in  each  eye. 

This  patient  did  not  wait  in  the  city  to  have  her  visual  apparatus 
corrected.  The  case,  however,  illustrates  well  the  existence  of  a  marked 
hyperopic  defect  and  muscular  insufficiency  as  a  cause  of  headache. 

Case  IV.  Excruciating  Headaches,  Chronic  Diarrhoea,  and  Neuralgic  Paroxysms. — 
Female,  aged  twelve. 

Family  History. — The  father  is  somewhat  eccentric  and  intemperate ;  jiulmonary 
consumption  was  extremely  common  among  the  paternal  ancestry ;  one  brother  is  an 
epileptic  and  is  partly  idiotic ;  all  the  paternal  side  of  the  family  are  very  excitable  and 
nervous  people. 

This  little  patient  was  a  great  sufferer.  Whenever  attenijjts  were  made  by  her  parents 
to  send  her  to  school,  she  would  "  break  down  "  at  once  with  peculiar  attacks,  characterized 
by  obstinate  vomiting,  chronic  diarrhoea,  intractable  headache,  and  neuralgic  pains  in  the 
spine,  limbs,  and  chest.  All  medical  treatment  had  proved  of  no  permanent  benefit.  So 
long  as  study  was  not  attempted,  the  child  suffered  only  at  intervals  with  these  severe 
attacks,  but  she  remained  weak  and  delicate. 


MIGRAINE — SICK-HEADACHE — MEGEIM.  537 

Eye-defects. — An  examination  of  her  eyes  showed  a  latent  hyperopia  of  nearly  3  D. 
and  esophoria  of  8°.  Prior  to  the  use  of  atropine  slie  had  normal  vision  (f  §).  The  wear- 
ing of  spherical  glasses  (2  D.)  and  ja-isms  (4°  over  each  eye  with  the  bases  out)  caused  all 
her  distressing  symptoms  to  disappear  within  two  weeks. 

A  letter,  lately  received  from  her  mother,  says :  "  I  thank  you  next  to  the  dear  Lord 
for  removing  this  burden  of  anxiety  about  my  child,  which  was  becoming  unbearable." 

Prisms  were  ordered  in  this  case  because  the  parents  decided  to  postpone  a  radical 
correction  of  the  muscular  error.     This  step  I  expect  to  undertake  very  soon. 

Case  V.  Orbital  Neuralgia  and  Sick-headaches. — Mr. ,  aged  forty-seven.    Patient 

is  a  lawyer.  Mother  has  had  sick-headaches  every  week  for  her  life-time,  confining  her 
to  bed.  Sister  is  "very  nervous."  Patient  has  suffered  personally  either  with  orbital 
neuralgia  or  sick -headaches  nearly  every  week  for  nearly  thirty  years.  The  attacks  usually 
last  two  days  and  require  from  one  to  three  grains  of  morphia  to  control  them.  They  seem 
to  be  independent  of  any  known  exciting  cause.  No  remedy  has  ever  been  found.  Patient 
has  consulted  several  of  our  best  physicians. 

Examination  of  the  eye  shows: — 

Normal  vision  before  atropine  was  instilled. 

A  latent  hyperopia  of  the  right  eye,  corrected  by  a  +  1.50  glass  ■^ 

A  latent  hyperopia  of  the  left    eye,  corrected  by  a  -)-  1.50  glass  J  P 

(0  D  ^r    I    4  25 
Reading  test  for  No.  1  Jaeger's  type,  under  atropine=  \     '     '         '    / 

External  insufficiency  (esophoria)  of  3°. 

I  ordered  this  patient  at  first  glasses  of  +  1.00  for  distance,  reading,  and  all  near- 
work.  The  insufficiency  at  first  appeared  to  be  corrected  without  prisms  by  his  "distance" 
glasses.    Subsequently  I  was  obliged  to  add  3°  of  prism,  as  he  refused  surgical  interference. 

Patient  experiences  great  relief  from  the  glasses  and  is  still  under  galvanic  treatment. 
The  neuralgic  attacks  are  apparently  occurring  at  less  frequent  intervals. 

Case  VI.  Excruciating  Neuralgic  Headaches. — Mr. ,  aged  thirty-nine.     Patient 

for  years  had  had  attacks  of  neuralgic  headache,  usually  hemicranic.  They  have  occurred 
•with  increasing  frequency  and  severity  for  the  past  few  years.  They  have  of  late  become 
almost  constant  and  have  rendered  the  patient  entirely  incapable  of  following  his  profession 
with  pleasure  or  profit. 

Examination  of  the  eye  shows: — 

A  latent  hyperopia  of  each  eye,  which  requires  a  -|-  2.75  glass  to  correct  it  when  the 
eye  is  under  atropine.     Without  atropine,  V.  ^  f§  in  both  eyes. 

External  insufficiency  (esophoria)  of  6°. 

With  corrected  vision,  by  means  of -f  1.50  glasses  and  3°  of  prism  over  each  eye, 
this  patient  has  almost  entirely  regained  his  health.  His  neuralgic  attacks  are  very 
infrequent  and  are  usually  traceable  to  excessive  use  of  the  adductor  muscles.  Patient 
still  wears  prisms  and  refuses  surgical  relief  for  his  esophoria. 

Case  VII.  Cerebral  Neurasthenia,  Pseudo-ataxia,  and  Chronic  Headache. — Male, 
married,  aged  forty-three. 

Family  History. — Two  brothers  died  of  phthisis,  one  uncle  of  paralysis ;  maternal 
ancestors  are  nervously  predisposed;  two  children  of  the  patient  sufi'er  from  nervous 
disturbances. 

Eye-defects. — Hyperopia  (latent)  of  2  D.     Esophoria  of  7°  (manifest). 

This  gentleman  was  a  great  sufferer.  Had  been  forced  to  give  up  his  business  from 
constant  distress  in  the  head,  which  was  aggravated  by  any  mental  labor.     He  walked 


538  LECTURES   ON   NERVOUS   DISEASES. 

with  difficulty  on  account  of  a  feeling  of  great  insecurity,  and  closely  simulated  the  gait 
of  an  ataxic.  He  ate  poorly  and  slept  badly.  No  organic  disease  could  be  found,  and 
electrical  treatment  was  thoroughly  tried,  and  proved  of  little  benefit.  Within  twenty- 
four  hours  after  a  tenotomy  of  his  internal  rectus  was  performed  he  ceased  to  have  pain 
in  his  head,  walked  with  greater  ease  than  for  many  months,  and  left  for  his  distant  home 
within  a  week,  provided  with  +  1  D.  spherical  glasses.  The  last  report  from  him  noted 
a  slight  tendency  toward  a  return  of  his  bad  feelings,  and  he  was  advised  to  have  his  eyes 
again  examined  to  ascertain  if  any  latent  esophoria  remained  to  be  corrected. 

In  his  last  letter  he  says :  "I  have  not  had  a  sick-headache  since  leaving  New  York, 
and  much  less  of  the  neuralgic  pain  in  the  neck  and  other  parts." 

Cases  VIII  and  IX.    Asthenopia   and  Sick-headaches. — Mr.  and   Mr.  , 

unmarried,  aged  respectively  twenty-one  and  twenty-two.     Both  were  college  students. 

Family  Histories. — Headaches  were  common  in  their  immediate  relatives  and  ancestors, 
and  in  one  phthisis  was  found  to  have  affected  the  ancestry. 

Eye-defects. — Both  had  slight  latent  hyperopia  and  esophoria  (manifest)  of  a  moderate 
degree. 

These  were  typical  cases  of  asthenopia  and  sick-headache.  Both  wore  prisms  for  a 
while  with  benefit,  but  they  found  that  a  latent  esophoria  showed  itself,  and  required  a 
change  of  the  strength  of  the  prisms.  The  stronger  prisms  caused  them  some  distress  in 
walking.  They  both  underwent  an  operation  for  the  radical  correction  of  the  defect,  and 
have  remained  entirely  free  from  asthenopic  symptoms  and  headache  up  to  the  present 
time.  The  necessity  of  wearing  glasses,  which  was  thus  dispensed  with,  is  a  matter  of 
delight  to  both. 

In  one  of  these  cases,  a  marked  tendency  to  dyspepsia  and  chronic  constipation  has 
apparently  been  entirely  overcome. 

The  last  tests  made  of  the  eyes  of  these  patients  showed  an  entire  absence  of  muscular 
defect  in  the  orbits. 

Case  X.    Chronic  Neuralgic  Headaches  of  Twenty-six  Years'  Standing. — ]\Irs. , 

widow,  aged  forty ;  has  had  two  children. 

Family  History. — Father  died  of  paralysis.  Mother  had  "suffocating  spells"  all  her 
life  One  sister  was  treated  for  vaginismus.  Dyspepsia  is  a  "  family  ailment."  No 
phthisical  tendencies,  as  far  as  known.    Her  oldest  child  is  "very  nervous." 

Eye-defects. — Myopia  ( — 2.50  S.);  hyperopic  astigmatism  (-|-  0.75  c.  and  +  1-50  c); 
hyperphoria  of  4°  (manifest);  adduction,  24°;  abduction,  8°. 

Since  a  child,  this  patient  has  had  terrible  headaches.  They  are  often  preceded  by 
blindness.  Since  her  marriage  they  have  increased  in  frequency  and  severity.  She  has 
(on  an  average)  two  each  week.  She  has  frequently  been  in  complete  coma  for  twenty- 
four  hours  from  pain,  and  "it  generally  takes  forty-eight  hours  to  recover  her  strength 
sufficiently  to  get  about  the  house." 

She  has  had  twenty-six  teeth  drawn,  in  the  vain  hope  of  getting  rid  of  the  head- 
aches, which  have  been  pronounced  as  "  neuralgic." 

Prior  to  her  deliveries,  while  pregnant,  she  would  oftentimes  become  suddenly  uncon- 
scious several  times  a  day.  These  attacks  were  apjiarently  "epileptoid"  in  character.  No 
uterine  disease  or  deflection  has  ever  been  found,  although  repeatedly  sought  for. 

This  patient  was  treated  at  the  first  interview  by  a  partial  tenotomy  of  one  superior 
rectus  muscle,  as  her  hyperphoria  was  of  a  very  marked  character,  even  after  the  correction 
of  her  refractive  error  by  glasses. 

On  the  following  day,  some  two  degrees  of  latent  hyperphoria  developed  and  was 
corrected  by  a  second  operation.  She  was  sent  to  her  home  in  a  distant  state  within  a 
week,  provided  with  proper  glasses  for  constant  wear. 


MIGRAINE — SICK-HEADACHE — MEGEIM.  539 

Since  her  return,  some  six  months  have  elapsed  and  she  has  had  but  two  headaches, 
both  of  which  she  attributes  to  very  marked  excitement  and  pliysical  fatigue.  She  states 
that  her  physical  condition  has  improved  to  a  remarkable  degree. 

Such  cases  as  the  last  one  narrated  certainly  justify  an  earnest 
inquiry  regarding  the  cause  and  proper  methods  of  cure  of  chronic  head- 
ache. This  hopeless  sufferer  recovered  without  drugs  and  with  little  or 
no  inconvenience. 

Treatment. — In  my  opinion,  the  first  step  toward  a  cure  in  these 
cases  is  to  examine  the  eyes  when  full}^  under  the  influence  of  atropine, 
and  to  carefully  ascertain  the  amount  of  refractive  error  which  exists. 
(See  p.  146.) 

If  a  high  degree  of  hyperopia^  with  or  without  hyperopic  astigma- 
tism, be  detected,  it  is  often  well  to  keep  the  patient's  eyes  under  atropine 
for  a  period  varying  from  one  to  several  weeks.*  During  this  period, 
the  patient  should  wear  constantly  a  glass  that  corrects  the  hyperopia 
(less  one  dioptre — a  glass  of  about  thirty-six  inches  focus |);  and  a 
stronger  glass  may  be  ordered  while  the  patient  is  under  atropine  for  such 
near-work  as  he  is  obliged  to  perform  with  his  eyes.  This  glass  takes 
the  place  of  the  normal  accommodation,  which  is  paralj^zed  by  atropine. 
For  example,  if  a  hj'peropia  of  three  dioptres  is  found,  the  patient  should 
wear  a  +  2.00  glass  for  distance,  and  while  under  atropine  his  power  of 
accommodation  must  be  temporarily  furnished  b}^  the  use  of  a  convex 
glass  of  sufficient  strength  to  enable  him  to  read  ordinary  t}- pe  with  ease 
at  fourteen  inches.  When  atropine  is  discontinued,  the  latter  glass  must 
be  dispensed  with  as  soon  as  the  ciliary  muscle  begins  to  assert  itself; 
hence,  these  patients,  unless  presbyopic,  need  but  one  glass,  which 
answers  both  for  distance  and  near-work  after  the  effects  of  atropine 
have  passed  aw^a}'.  If  the  patient  be  simply  astigmatic,  the  full  correc- 
tion will  generally  be  tolerated  by  the  patient,  after  the  ettects  of  atropine 
have  subsided.  These  cases  do  not  require  a  prolonged  use  of  atropine, 
as  a  rule. 

If  the  muscles  of  the  eye  are  found  to  be  out  of  balance,  prisms  may 
be  added  to  the  glass  which  is  selected  to  correct  the  refractive  error  ; 
in  case  the  patient  absolutely  refuses  to  have  a  partial  tenotomy  per- 
formed. I, am  personally  opposed  to  the  constant  use  of  prisms,  save  as 
a  dernier  ressort ;    partl^Miecause  all  patients  cannot  wear  them  with 

*This  step  is  taken  to  ensure  a  decrease  in  the  power  of  a  hypertrophicd  ciliary 
muscle,  which  would  oppose  attempts  to  correct  a  high  degree  of  hyperopia  which  had 
been  "  latent." 

t  A  glass  of  one  dioptre  is  in  reality  about  40  inches  focus.  Practically,  the  subtrac- 
tion is  necessary  of  l-ofi  from  the  glass,  which  atfords  full  correction  of  the  refractive 
error.  It  is  tolerated  by  the  patient  if  he  wears  such  a  glass  constantly,  and  afford,  g.eat 
comfort  when  the  ciliary  muscle  ceases  to  exert  its  action  in  viewing  objects  beyond  the 
20-foot  radius. 


540  LECTURES   ON   NERVOUS   DISEASES 

comfort,  and  also  from  a  knowledge  of  the  fact  that  the  "  manifest  " 
insufiiciency  which  the  prisms  correct  is  not  usually  all  that  actually 
needs  correcti(jn.  Prismatic  glasses  freiiuently  render  the  appearance 
of  the  sidewalk  or  lioor  apparently  concave  to  a  patient  when  first  worn. 
This  effect  soon  tends  to  pass  away.  It  is  very  annoying  to  some  su))- 
jects,  and  they  should  be  prepared  for  it  by  timely  explanation. 

Considerable  difficulty  may  be  experienced  in  getting  patients  to 
persevere  in  the  wearing  of  glasses  for  a  latent  hyperopia,  after  the 
effects  of  atropine  have  already  subsided.  The  ciliary  muscle  of  each 
eye  invariably  tights  the  glass  to  a  greater  or  less  extent,  because  it  has 
long  been  accustomed  to  excessive  action  in  bringing  the  eye  to  a  focus 
both  for  distant  and  near  objects.  This  accounts  for  the  fact  that  these 
patients  often  experience  a  dimness  of  vision  at  times  through  the 
glasses  (which  passes  off  as  soon  as  the  glasses  are  removed).  I  have 
known  vertigo,  nausea,  and  even  vomiting  to  occur  from  this  conflict 
between  the  ciliary  muscle  and  the  glass. 

Patients  should  be  told  that  these  difficulties  are  apt  to  arise  for 
some  weeks  or  months  at  intervals,  and  that  they  must  persevere  in 
wearing  the  glasses  ordered,  even  if  they  have  to  remove  them  for  a  few 
minutes  at  a  time  whenever  they  become  particularly  annoying.  It  is 
not  enough  for  them  to  use  their  glasses  for  reading  or  writing  only. 
The  "eye-strain"  must  be  overcome  without  interruption,  if  we  are  to 
expect  a  cure.  These  patients  will  very  often  tell  j^ou  "  that  they  can 
see  better  without  their  glasses  than  with  them;"  and  they  may  narrate 
in  a  complaining  tone  all  the  inconveniences  of  wearing  a  glass  constantly, 
such  as  irritation  of  the  nose,  the  trouble  of  cleaning  them,  the  accumu- 
lation of  moisture  or  snow  upon  them,  the  disfigurements,  etc.  With 
such  complaints  I  constantly  have  to  deal  by  impressing  them  with  the 
benefits  derived  from  the  glasses,  the  difference  between  seeing  without 
effort  and  seeing  with  eye-strain,  the  necessity  of  strict  compliance 
with  my  directions,  etc.  The  wearing  of  spectacles  or  nose-glasses 
constantly  is  at  best  a  nuisance,  and  to  ladies  they  are  sometimes  veay 
repulsive;  but  when  the  choice  between  sick-headaches  and  glasses  is 
intelligently  discussed  before  this  class  of  sufferers,  it  is  very  uncommon 
to  find  a  rebellious  patient. 

During  a  paroxysm,  what  is  to  be  done  for  the  patient?  In  the 
prodromal  stage,  give  a  good  purgative  or  an  emetic  early.  If  you  delay 
it  until  late  in  the  day  the  paroxysm  will  reach  its  height.  I  frequently 
give  compound  cathartic  pills  (three  or  four  at  a  dose),  and  follow  it  in 
two  hours  with  warm  water  as  an  emetic. 

Sometimes  full  doses  of  bromo-caffeine,  or  the  fluid  extract  of 
guarana  in  drachm  doses  (repeated  if  necessary),  or  large  doses  of 
qvunine  (ten  to  twenty  grains),  or  copious  draughts  of  very  hot  water, 


NEURALGIA.  541 

will  cut  an  attack  short.  Aiitipyr'me,  in  doses  of  two  to  five  <2:iaius  every 
hour,  will  often  cure  an  attack,  even  when  excessively  severe.  These 
remedies,  however,  are  liable  to  prove  inelfectual  when  most  needed. 

When  the  i)ain  becomes  very  severe,  immersion  of  the  entire  body 
in  a  very  hot  bath  will  almost  always  give  relief.  A  bag  partially  lilled 
with  hot  water  })laced  at  the  back  of  the  neck  after  the  bath  is  very 
agreeable  to  most  sufferers  of  this  class  and  frequently  induces  sleep. 

The  patient  should  be  placed  in  a  darkened  room  and  all  noises 
should  be  excluded.  Finally,  a  full  dose  of  morphia  may  be  required  in 
extreme  paroxj'sms.  Of  all  the  remedies  that  my  personal  experience 
has  proved  to  be  effectual,  a  brisk  purgative  and  the  hot  bath  are  the 
most  liable  to  relieve  the  patient  promptly. 

I  have  never  observed  anj^  decidedly  curative  effects  from  medica- 
tion or  electrical  applications  during  the  intervals  between  the  par- 
oxysms. The  intervals  may  be  prolonged  somewhat,  in  some  cases,  by 
tonics,  out-of-door  sports,  or  exercise,  a  regular  life,  care  in  the  diet,  etc. ; 
but  the  paroxysms  tend  to  return  with  severity  in  spite  of  every  known 
precaution,  until  the  ej'e-strain  is  removed. 

Of  late,  considerable  attention  has  been  given  to  the  dependence  of 
headache  in  certain  cases  upon  a  partial  or  complete  obstruction  of  the 
nasal  passages  due  to  hypertrophy  of  the  mucous  covering  of  the  turbi- 
nated bones  or  deflections  of  the  nasal  septum.  These  conditions  are 
more  commonly  encountered  than  one  would  at  first  imagine. 

Probably  deflections  of  the  septum  are  due  in  part  to  blows  received 
upon  the  nose  during  childhood. 

The  explanation  of  the  development  of  headache,  in  consequence  of 
an  obstruction  in  the  nares  of  sufficient  extent  to  interfere  with  the 
oxygenation  of  the  posterior  nares  in  the  vault  of  the  pliar3^nx,  seems  to 
be  that  of  reflex  irritation  of  the  nerves  distributed  to  that  part,  which 
probably  induces  vaso-motor  disturbances  within  the  cranium. 

While  my  experience  in  the  removal  of  such  obstructions  by  means 
of  the  nasal  trephine,  the  nasal  saw,  and  applications  of  chromic  acid  or 
the  actual  cautery  is  not  extensive,  I  can  bear  testimon}'  to  the  fact  that 
I  have  encountered  cases  where  this  step  has  led  to  marked  relief  of 
headache.  I  believe  that  in  typical  sick-headache  occlusion  of  the  nares 
is  less  frequently  observed  than  in  those  cases  which  suffer  from  the 
so-called  "  catarrhal  "  headaches.  These  are  less  paroxysmal  and  severe 
than  typical  attacks  of  migraine. 

NEUEALGIA. 

In  view  of  the  fact  that  different  authors  include  under  this  head 
widely  varying  conditions  which  are  associated  with  paroxysmal  pain, 
it  may  be  well  to  state  early  what  my  conception  of  the  term  embraces. 


542  LECTUEES   ON  NERVOUS  DISEASES. 

It  seems  to  me  that  the  term  "neuralgia"  cannot  be  properl}'  applied  to 
paroxysms  of  pain  which  are  clearly  traceable  to  organic  changes  in  the 
brain  or  spinal  cord.  On  the  other  hand,  it  is  equally-  clear  to  my  mintl 
that  typical  attacks  of  neuralgia  of  a  very  persistent  and  obstinate  kind 
may  occur  without  the  existence  of  organic  changes  in  the  nerves 
themselves. 

I  have  for  some  time  regarded  most  neuralgic  attacks  rather  as  a 
S3'mptom  of  an  existing  "  neuropathic  predisposition,''  which  has  been 
either  created  by  or  subjected  to  some  marked  reflex  irritation,  than  as 
clinical  evidence  of  existing  disease  in  the  nerves.  This  condition  of 
reflex  irritation  is  encountered  not  alone  in  subjects  who  have  fleeting 
attacks  of  pain  in  various  nerves  at  ditfei'ent  times.  It  is  met  with  often 
in  those  who  suffer  from  paroxysms  of  severe  pain  with  more  or  less 
periodicity'  in  some  special  nerve-trunk  or  its  branches.  It  is  my  opinion 
that  a  very  large  proportion  of  neuralgias  are  totally-  independent  of 
pathological  lesions  either  in  the  nerves  or  the  nerve-centres;  and  that 
but  a  small  proportion  are  the  direct  result  of  morbid  changes.  This 
subject  will  be  discussed  further  when  the  causes  of  neuralgias  are 
considered. 

Neuralgia  must  not  be  confounded  with  neuritis.  The  latter  condi- 
tion is  an  inflammatory  one;  in  which  the  S3anptoms  are  not  parox3'smal 
but  constant  while  thej'^  last,  and  are  not  infrequently  accompanied  by 
marked  disturbances  of  motility  and  sensibility,  and  also  of  muscular 
nutrition. 

Although  the  existence  of  certain  tender  points  in  the  course  of  a 
nerve  (where  pressure  is  acutely  felt  and  usually  accompanied  hy  pain 
along  the  nerve — the  so-called  "  puncta  dolorosa  "  of  Yalleix)  is  generally 
considered  as  peculiarl}-  diagnostic  of  neuralgia,  there  maj'  be  cases  of 
tj'pical  neuralgic  paroxysms,  in  my  opinion,  where  these  tender  points 
are  not  to  be  detected  after  a  careful  examination. 

The  '■'■puncta  dolorosa'''  are  to  be  sought  for,  as  a  rule,  near  the 
orifices  of  bony  canals  or  foramina  through  which  the  affected  nerve 
escapes,  or  where  the  nerve  subdivides,  anastomoses,  or  pierces  a  fascia. 
In  my  work,  "  The  Applied  Anatomy  of  the  Nervous  System,"  I  have 
described  the  situation  of  these  tender  points  for  the  more  important 
nerves  of  the  bod3\     Space  precludes  a  full  discussion  of  this  field  here. 

Etiology. — The  causes  of  neuralgia  may  be  classified  as  follow:  (1) 
The  predisposing;  (2)  the  modifying;  and  (3)  the  exciting. 

The  predisposing  causes  of  neuralgia  (like  those  of  other  functional 
neuroses)  comprise  all  constitutional  or  acquired  conditions  which  tend 
to  create  the  so-called  "neuropathic  tendencv." 

It  is  generally  recognized  that  in  this  particular  class  of  nervous 
subjects,  hereditar3-  influences  may  be  observed  in  a  ver3-  large  proportion 


NEURALGIA.  543 

of  cases  when  carefully  sought  for.  We  find,  not  infrequently,  that 
neuralgia  has  been  present  in  different  branches  of  the  family  for  several 
generations ;  or  that  some  other  evidences  of  a  nervous  taint  have  occa- 
sionally appeared, — such,  for  example,  as  hysteria,  epileps}-,  chorea, 
insanitv,  etc.  Again,  a  tubercular  tendenc}'  is  very  commonly  detected 
in  the  ancestry  of  neuralgic  subjects.  Finally,  neuralgia  ma^-  be  shown 
in  some  cases  to  be  indirectly  a  result  of  general  anjemia,  chlorosis, 
neurasthenia,  and  other  similar  states,  which  may  have  been  iiiduced  by 
excesses,  over-exertion  of  the  mind  or  body,  prolonged  anxiety,  diarrhoia, 
or  lactation,  and  many  other  similar  causes. 

Now,  I  believe,  from  a  somewhat  extended  research  into  the  probable^ 
factors  which  tend  to  induce  the  "neuropathic  tendency,"  that  "■eye- 
strain'''' and  ^^ abnormal  eye-tension^^  are  perhaps  more  closely-  related  to 
this  obscure  and  imperfectly  understood  condition  than  any  other  factors 
which  have  as  3'et  been  observed.  Dental  and  ovarian  irritation  are  also y 
peculiarl}'  liable  to  induce  neuralgic  paroxysms. 

It  is  safe  to  assert  that  comparatively  few  cases  of  neuralgia  are  ever 
subjected  during  their  lives  to  eye-tests  made  in  a  scientific  manner  by 
competent  observers.  It  can  be  shown,  I  think,  that  until  recently-  the  tests 
made  by  mau}^  of  the  best  observers  in  this  field  have  been  more  or  less 
superficial  in  reference  to  the  state  of  the  eye-muscles;  and  that  the 
method  described  in  this  volume  (p.  145)  is  far  more  complete  and 
thorough  than  that  given  by  most  authors  on  ophthalmology.  It  is  not 
hard,  therefore,  to  understand  why  this  statement  is  not  more  generally 
accepted  by  the  profession  at  large.  The  medical  mind  is  now  rapidly 
becoming  awakened  to  the  necessity  of  such  tests  in  nervous  disturbances: 
as  well  as  to  the  importance  of  more  care  regarding  the  details  of  the 
methods  employed  by  those  who  make  the  tests.  Many  of  the  profession 
(who  are  not  oculists)  are  to-day  beginning  to  make  their  own  tests  for 
suspected  refractive  and  muscular  anomalies.  To  such  we  shall  soon 
owe  perhaps  more  valuable  information  respecting  the  relationship 
between  errors  in  the  orbit  and  functional  nervous  maladies  than  to 
oculists,  because  nervous  diseases  are  more  commonly  observed  in  general 
practice. 

Tlie  modifying  causes  of  neuralgias  come  next  in  order.  They 
comprise  all  forms  of  infectious,  toxic,  and  depressing  conditions  which 
tend  to  exert  a  deleterious  influence  upon  the  general  health  of  the 
patient.  In  this  way,  malarial  influences,  the  germs  of  the  various  fevers, 
poisoning  by  lead,  mercury,  alcohol,  tobacco,  etc.,  syphilis,  exposure  to 
cold  and  dampness,  over-fatigue,  nnd  many  other  similar  causes  may 
have  a  bearing  upon  the  causation  as  well  as  upon  the  relief  of  neuralgias. 
It  should  be  borne  in  mind,  however,  that  these  causes  are  usually 
engrafted  upon  some  one  or  more  of  the  predisposing  causes  mentioned. 


544  LECTURES   ON   NERVOUS  DISEASES. 

It  is  rare,  in  my  experience,  to  observe  cases  of  neuralgia  where  a  pre- 
disposing tendency  cannot  be  demonstrated.  I  think  we  are  all  apt  to 
attach  too  much  importance  to  the  modifying  and  exciting  causes  of 
functional  nervous  attaclvs.  I  believe  future  investigation  will  justify 
this  conclusion,  and  that  the  views  of  the  profession  must  undergo  a 
marked  reformation  respecting  this  painful  and  distressing  malady. 

The  exciting  causes  of  neuralgias  are  sometimes  very  difficult  to 
determine.  I  quote  from  Rosenthal,  who  aptly  says  :  '•  The  arrangement 
of  the  central  mosaic  {i.e.,  the  intermingling  of  nerve-roots  and  cells) 
determines  the  law  of  peripheral  manifestations."  It  is  often  a  matter 
of  difficulty  to  ascertain  (even  by  a  careful  examination  of  the  patient) 
whether  some  local  cause  may  not  exist;  or,  if  it  is  not  discovered, 
whether  some  form  of  reflex  irritation  is  not  helping  to  keep  the  neuralgic 
manifestations  active. 

Troul)le  with  the  teeth  may  start  up  either  a  trigeminal  neuralgia, 
or  an  earache,  or  some  other  reflex  disturbance,  which  often  proves 
obstinate  until  the  cause  is  removed  or  ameliorated.  Perhaps  a  perios- 
titis near  to  a  foramen  through  which  a  nerve  passes  may  light  up  a 
neuralgia  in  that  nerve.  Again,  in  inflammatory  exudations,  cicatrices, 
tumors  of  all  kinds,  and  other  conditions  may  occasionally  press  upon 
a  nerve  and  cause  neuralgic  manifestations.  Finally,  reflex  irritation 
from  the  eye,  nose,  mouth,  uterus,  ovaries,  intestine,  bladder,  clitoris,  or 
rectum  may  prove  to  be  exciting  causes  of  paroxysmal  pain  far  removed 
from  the  actual  cause. 

Of  all  these  reflex  causes,  I  regard  the  eye  as  probably  the  most 
common,  and  certainl}-  the  most  important  one  to  search  for  early  in  the 
examination.  So  generally  do  I  find  palpable  evidences  of  eye-defect  in 
these  cases,  that  I  have  many  times  questioned  whether  this  factor  does 
not  surpass  in  its  frequencj^  all  others  combined.  Congenital  errors  of 
refraction  and  anomalies  in  the  eye-muscles  are,  in  my  opinion,  the  chief 
factors  in  producing  the  "  neui'opathic  predisposition."  Their  continu- 
ance without  relief  tends  also  under  certain  physical  conditions  to  act  as 
a  reflex  cause  for  pain ;  as  well  as  for  the  more  serious  neuroses,  when 
the  subject  becomes  unable  to  endure  the  eye-strain  which  such  con- 
genital defects  entail.  That  this  conclusion  is  not  irrational,  the  effects 
of  removal  of  this  factor  in  many  cases  which  I  have  personalh'  observed 
clearly  demonstrates. 

Morbid  Anatomy. — As  a  rule,  it  may  be  stated  that  neuralgias  are 
seldom  dependent  upon  pathological  changes.  In  a  few  exceptional 
cases,  however,  the  nerves  and  the  nerve-centres  may  reveal  in  a  variety 
of  ways  the  existence  of  a  morbid  state.  These  morbid  conditions  may 
usuall}^  be  diagnosed  after  a  thorough  examination  of  the  case  and  a 
careful  stud}*  of  the  symptoms  has  been  made. 


NEURALGIA.  545 

In  the  nerve-trunks,  the  following  lesions  haA^e  been  observed  in 
reported  cases  where  neuralgia  has  been  a  marked  symptom:  (1),  con- 
gestion and  thickening  of  the  sheath  of  the  nerve;  (2),  neuromata;  (3), 
sclerosis  and  atrophy  of  the  nerve  ;  (4),  granular  degeneration  of  the 
axis-c3'linders ;  (5),  inflammation  or  degeneration  of  the  ganglia  on  the 
posterior  spinal  nerve-roots;  (6),  similar  changes  in  the  ganglia  of  the 
sensory  cranial  nerves;  (7),  simple  atrophy  of  the  nerve,  following 
pressure  upon  it  from  one  or  more  of  the  causes  previously  mentioned  ; 
and  (8),  capillary  hemorrhages  in  the  nerves  themselves. 

In  the  sjnnal  cord,  Anstie  has  claimed  theoretically  that  morbid 
processes  (atrophy  or  degeneration)  in  the  posterior  nerve-roots  or  in 
the  gray  matter  of  the  posterior  horns  probably  exist  in  neuralgia. 
Unfortunately  for  this  view,  pathological  research  has  failed  to  verify 
the  hypothesis.  Like  many  pure  hypotheses,  it  is  probably  without 
foundation. 

In  the  brain,  we  find  that  tumors,  softening,  inflammatory  ex- 
udations, tubercle,  hemorrhagic  clots,  and  many  other  morbid  con- 
ditions may,  under  certain  circumstances,  irritate  the  roots  of  some 
cranial  nerve,  or  the  trunk  of  the  nerve  itself.  These  morbid  conditions 
are,  however,  in  no  way  to  be  considered  as  pathognomonic  of  neuralgia.. 

The  cranial  nerves  may  in  some  instances  be  independently  affected 
with  any  of  the  changes  already  mentioned  in  connection  with  the- 
nerves. 

My  friend,  Dr.  C.  L.  Dana,  of  New  York,  has  lately  contributed  am 
article  to  the  literature  of  neuralgia  based  upon  the  clinical  study  of 
453  cases.  Some  of  his  deductions  are  of  value  in  this  connection,  and 
therefore  quoted. 

Respecting  the  percentage  of  the  various  types,  his  statistics  show 
that  41  per  cent,  were  of  the  trigeminal  type  ;  23  per  cent,  of  sciatic  ;  13 
per  cent,  of  the  intercostal ;  4.5  per  cent,  of  cervico-occipital ;  2.5  pei 
cent,  of  lumbo-abdominal ;  2  per  cent,  of  articular;  and  about  2  per  cent, 
of  brachial. 

Respecting  the  season  of  the  year  which  is  most  frequently  attended 
with  neuralgic  attacks,  he  shows  that  winter  and  fall  have  a  larger  pro« 
portion  than  spring  and  autumn. 

Regarding  the  age  of  patients  so  afflicted,  he  shows  that  45  percent, 
developed  before  the  thirtieth  year. 

The  influence  of  sex  seems  to  be  apparent.  Females  are  shown  to 
be  attacked  more  commonly  than  men  in  the  proportion  of  5  to  3. 

In  this  paper,  migraine  is  classed  as  a  type  of  neuralgia.  Un- 
fortunately, in  my  opinion,  while  admitting  "  the  neuropathic  predis- 
position "  and  marked  "  family-tendency  "  to  neuralgia  in  any  or  all  of 
its    forms,  this    author   does    not    bring   into  pi'ominence  the   common 

35 


546  LECTURES  ON  NEEVOUS  DISEASES. 

relationship  between  eye-strain  and  these  attacks  which  is  now  being 
very  generally  recognized. 

In  siuninary,  it  may  be  said  tliat  we  are  forced  to  admit  that  the 
pathology  of  neuralgia  is  as  yet  undetermined.  It  has  been  sought  for 
by  a  host  of  enthusiastic  pathologists  without  an}^  satisfactory  results.' 

The  morbid  conditions  which  have  been  previously  enumerated  as 
haA'ino-  been  found  in  exceptional  cases  are  probably  the  last  to  be  clin- 
ically suspected,  w^henever  the  paroxysms  of  pain  are  unassociated  with 
motor,  sensory,  or  trophic  disturbances  between  the  paroxysms.  All 
of  the  later  observations  of  Dr.  Stevens  and  myself  go  to  show  that 
neuralgic  attacks  are  curable  in  a  large  proportion  of  cases  when  treated 
by  the  relief  of  eye-strain.  This  fact  is  incapable  of  explanation  if  the 
presence  of  pathological  lesions  of  the  brain,  spinal  cord,  or  the  nerves 
atfected  with  neuralgic  paroxysms  is  admitted.  Like  other  purely 
functional  neuroses,  the  detection  of  the  cause  and  the  removal  of  an 
irritation  (generally  of  a  reflex  type),  which  a  thorough  examination  of 
the  case  will  usually  reveal,  results  in  permanent-  benefit  to  the  patient 
and  a  more  or  less  complete  cessation  of  the  attacks. 

Symptoms. — The  chief  symptom  of  this  affection  is  pain.  This 
symptom  is  characterized  by  the  following  peculiarities  : — 

(1)  It  is  very  acute,  paroxysmal,  and  usually  intermittent. 

(2)  If  remittent,  the  remissions  are  ver^-  distinctl}^  marked. 

(3)  The  pain  is  generally  unilateral. 

(4)  It  follows  the  course  and  distribution  of  a  nerve. 

(5)  Tender  points  {jouncta  dolorosa)  are  generall}-  present. 

(6)  The  general  health  is  but  little  atfected. 

(7)  Inflammatory  symptoms  are  absent. 

(8)  Abnormal  phenomena  of  a  sensory,  motor,  and  trophic  kind  may 
be  associated  with  the  attacks  of  pain,  but  do  not  exist  between  the 
paroxysms. 

The  table  on  the  opposite  page  will  aid  the  reader  in  distinguishing 
the  diagnostic  points  which  are  to  be  clinically  observed  in  cases 
aflfiicted  with  various  t^'pes  of  neuralgia.  Some  other  diseases  which 
simulate  neuralgia  will  be  contrasted  with  it  later. 

Clinically  we  are  forced  to  recognize  two  great  classes  of  neuralgic 
patients,  viz.,  those  who  have  mild  and  infrequent  attacks,  and  those 
whose  sufferings  are  almost  without  intermission. 

A  careful  scrutiny  of  this  table  will  make  the  prominent  features  of 
tic-douloureux,  cervico-occipital  neuralgia,  cervieo-brachial  neuralgia, 
intercostal  neuralgia,  mastodynia,  lnml)o-abdominal  neuralgia,  and 
sciatica  more  apparent  than  a  long  description.  Such  a  table  aids  the 
reader,  moreoA'er,  in  contrasting  the  chief  symptoms  of  the  special  types 
of  neuralgia  most  frequently  encountered  in  medical  practice. 


NEUKALGIA. 


547 


91 

=■2:3 

S  3   M 
^     •  0 

s.    a 

B  g  M 

c* : 

0 
11 

n 

•< 

0 
•5 

Pressure-points 

Region  of  Pain 

(During  paroxysm.) 

r  Convulsive  spasms  of 
1    the  face,   and   occa- 
■{    sionally  of  the  neck. 
1  The  limbs  may  becon- 
L  vulsed  in  rare  cases. 

fSkin       eruptions; 
J    blanching   of    hair; 
']    glaucoma:    iritis; 
[  choroiditis. 

. 

S     Supraorbital     fora- 
"s  1    men. 

:5  '  Parietal  eminence. 
"s     Inner  angle  of  eye. 

•■S  1  Infraorbital      fora- 
S  1    men. 
!^  V  Malar  region. 
a,    Upper  lip. 
ig  J  Alveolar  processes. 

"^  H  1  Mental  foramen. 
>5 1^  I  Side  of  tongue. 

f  Depends  on  branch  of 
1    nerve    involved— the 
^    ophthalmic,     supra- 
maxillary  or   infra- 
[  maxillary. 

c  S  r. 

SIS 

Most  frequent  in  fe- 
males.     Ophthnhnic 
branch     most    often 
affeu-ted.        Entire 
nerve  rarely  attach- 
ed.    Generally  uui- 
^  lateral. 

j  Movements   of   head 
[   seriously    interfered 
with    during    par- 
oxysms. 

Redness  of  a  lateral 
half  of  the  face ;   in- 
jection   of   conjunc- 
tiva;       contracted 
pupil:    excessive 
.  secretion  of  tears. 

Most  frequent  in  fe- 
males from  twenty  to 
fifty  years  of  age. 
Occipitalis  in  a  J  0  r 
nerve  generally 
att.acked. 

Generally  unilateral. 

Between  mastoid  pro- 
cess and  1st  cerv. 
■    vertebne. 

Cervical  spinous  pro- 
cesses. 

Occiput  and  back  of 
neck. 

May  extend  to  ear, 
scapulse,  and  chest 
(in  severe  cases). 

0 
0 

8 

H 
l» 

■  Fibrillary  twitchings; 
tonic  or  clonic 
spasms ;    paresis    or 

•  paralysis ;  iierma- 
nent  extension  of  the 
fingers ;  contracture 
of  muscles. 

Pallor   or  redness   of 
skin ;    profuse  sweat- 
ing;   skin  eruptions; 
excessive   growth    of 
hair;     changes     i  n 
nails ;  glossy  skin. 

Most  frequent  i  u 
males.  Right  side 
usually  attacked. 

May  follow  trauma^ 
tism,  lead  poisoning, 
joint  diseases,  etc. 

Generally  unilateral. 

. 

CERVICO-BRACHIAL 

(Neuralqia  of  Brachial 

Plexus). 

Vary  with  the  branch- 
es   of    the    brachial 
jilexus  attached. 

Near  internal  condyle 

Near  head  of  ulna. 

Bicipital  depression. 

Lower  any  of  scapula 

Axillary  fossa. 
.  Spinous  processes. 

May   be    confined    to 
area  of  distribution 
of  the  median,  ulna, 
m  use  u  lo-sp  ira  I,  s  ub- 
st/pnlar,  and  siipra- 
claciiular    branches 
of  brachial  plexus. 

1 

/ 

Is 

c  0 

Body  often  bent    to- 
ward painful  side. 
*  Breathing  superficial. 
Voice  feeble. 

Herpes  zoster. 
Offensive  perspiration 
Cardiac  neuroses. 
Localized  aniesthesia. 
"     hyperesthesia. 

Most  frequent  in  fe- 
males. Followsmal.a- 
ria,  injury,  chlorosis, 
exposure,"  pleurisy, 
phthisis,  typhoid, 
lead  poisoning,  etc. 
Most  frequent  on  left 
side.   Generally  uni- 

.  lateral. 

Close  to  spinous  pro- 
cesses of  thevertebrse 
^ vertebral  point). 

Axillary  line  of  chest 
over  affected  nerve 
(lateral  point). 

Edye  of  sternum  (ster- 
nal point). 

Rarely  in  dorsal 
branches  of  theinter- 
costal  nerves. 

5th  to  9th  nerves  most 
often  attacked. 

May  extend  into  arm. 

Vomitingfrequent(at 
heigh  t  of  paroxysm ) . 

Exclusively      in     f  e  - 
males.    D  e  v  e  1  oj  s 
after  puberty.    Nodu- 
lar   indurations     are 
not    infrequent    dur- 
ing paroxysm.    Is  apt 
to   be  Jiersistent   and 
obstinate.     Often  bi- 
lateral. 

Is 

£'■< 

c  d? 
123 

lit 
a>  -1 

5'S* 

Are  inconstant. 
Nipi)les  very  tender. 
Sore    spots    may    be 

detected     over     the 

breasts. 

'Most  marked  in  the 
breasts.      2d  to    titli 
intercostals    are    at- 
tacked.   Nipple  very 
sensitive.    Ma^  radi- 
ate into  neck,  shoul- 
der or  back. 

r  Seminal  emissions. 
1  Spasm    of    cremaster 
■{    muscle    (retracted 
1    testicle), 
t  Vesical  tenesmus. 

B  g. 

i! 

■g.  s 

B     S; 

"  5' 

0? 

. 

0 

§ 

a 
5 

^  simultaneously. 

Afl'ects  both  sexes 
equally. 

May  follow  spinal 
caries,  spinal  menin- 
gitis, etc. 

Most  frequent  on  left 
side. 

Generally  unilateral. 

Near  spines  of  lumbar 

vertebra;. 
Middle     of    crest     of 

ileum. 
On  scrotum  or  labium. 

Affects  areas  of  dis- 
tribution of  the  /«»«- 
bar  plexus: — 

1.  Region  of  hip  and 
hypogastrium.  2. 
Groin  and  inner  part 
of  thigh.  3.  Scrotum 
and  testicle.  Several 
nerves  often  attacked 

Most      frequent       i  n 
males  (20  to  60  years 
of    age).     Follows 
traumatism,  expos- 
ure,    gout,     rheuma- 
tism, syphilis,  mala- 
ria,   etc.      Generally 
unilateral. 

2 

a 

Vomiting  (at  height 
of  paroxysm). 

Tonicor  clonic  spasms 
of  leg. 

Paresis. 

Posture  in  bed  (usu- 
ally on  healthv  side, 
with  afiected  leg 
fiexed  at  thigh  and 
^  knee). 

|i' 

'  1 

Abnormal  redness  of 
skin;      excessive 
growth  of  hair;  ex- 
cessive sweating; 

Apt  to  be  inconstant 
or  wanting. 

Lower  border  of  glu- 
teus maximus. 

Behind  trochanter  of 
femur. 

Middle    of   back    of 
thigh. 

Bend  of  knee. 

Below  head  of  fibula. 

Behind  the  malleoli. 
^  Dorsum  of  foot. 

May  affect  individual 
branches      of     the 
nerve.  U whole  nerve 
is  attacked,  pain  is 
felt  in  buttock,  pos- 
terior part  of  thigh, 
leg,  and  all  the  loot 
but  the  inner  side. 

548  LECTURES   ON   NERVOUS  DISEASES. 

A  few  points  mn,}'  be  mentioned  separately,  however,  wliich  have  more 
than  ordinary  diagnostic  importance  in  tliese  affections. 

(1)  The  discrimination  between  neuralgic  attacks  which  follow  the 
development  of  some  organic  cerebral  lesion  and  ordinary  neuralgia  is 
clinically  of  great  importance.  It  modifies  materially  the  prognosis  and 
the  treatment. 

(2)  The  pains  of  the  first  stage  of  locomotor  ataxia  are  very  often 
mistaken  for  neuralgia  and  rheumatism.  In  my  experience,  it  is  rarel3'^ 
my  privilege  to  encounter  a  case  of  this  spinal  disease  where  the  subject, 
through  an  incorrect  diagnosis,  has  not  been  medicated  for  the  relief  of 
one  of  these  conditions  for  a  longer  or  shorter  time  before  he  is  brought 
to  my  notice.  The  peculiarities  of  ataxic  pains  have  already  been  quite 
fully  described. 

(3)  Organic  spinal  lesions  of  the  "  non-systematic  "  type  are  very 
apt  to  be  mistaken  for  neuralgia. 

(4)  Vertebral  caries  is  a  prolific  source  of  pain  in  the  young  which 
may  be  referred  to  parts  which  are  remote  from  the  spine.  I  recall  a 
case  where  persistent  pain  over  the  stomach  (produced  indirectly  by 
caries  of  the  spine)  was  treated  for  mau}^  months  by  medication,  to  the 
serious  detriment  of  the  child. 

The  table  opposite  may  aid  the  reader  in  making  the  discriminations 
mentioned. 

In  trigeminal  neuralgia  the  situation  of  the  pain  and  the  locality  of 
the  "  pressure  points  "  varies  with  the  branch  of  the  nerve  which  is 
affected.  It  is  very  rarely  bilateral,  and  seldom  alternating  in  character. 
The  ophthalmic  branch  is  most  often  attacked.  When  accompanied  by 
spasm  of  the  facial  muscles,  it  is  known  as  ^^  tic  convulsif.''^  Muscular 
movements  increase  the  pain  of  neuralgic  attacks ;  hence,  chewing, 
laughing,  talking,  etc.,  are  apt  to  be  studiously  avoided  during  these 
attacks. 

In  sciatica  we  have  one  of  the  most  common  and  rebellious  types  of 
neuralgia.  Exertion  of  any  kind,  such  as  sitting  or  walking,  is  apt  to 
increase  the  severity  of  a  paroxysm  or  to  hasten  the  approach  of  an 
attack.  It  is  most  common  in  middle  life,  and  very  rarely  encountered 
in  childhood.  It  may  be  associated  with  a  neuritis.  If  so,  the  intervals 
between  the  paroxysms  are  apt  to  be  associated  with  an  aching,  burn- 
ing, or  bruised  feeling  in  the  leg.  The  muscles  not  infrequently  undergo 
atrophy  in  eases  of  long  standing. 

The  skill  eruptions  which  follow  or  accompany  neuralgic  attacks 
comprise  herpes,  pemphigus,  psoriasis,  er3'thema,  and  urticaria. 

The  duration  of  neuralgic  attacks  varies  from  a  few  minutes  to 
several  days.  Paroxysm  generally  follows  ])aroxysm  with  more  or  less 
rapidity  during  the  attack;  while  pain  of  a  less  severe  type  is  often  felt 


NEURALGIA. 


549 


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550  LECTUEES   ON   NERVOUS   DISEASES. 

during  the  intervals.  Sometimes  the  approach  of  an  attack  is  indicated 
by  certain  prodromata,  such  as  formication,  tingling,  or  a  feeling  of 
stiffness  in  a  part. 

The  frequency  of  neuralgic  attacks  depends  upon  the  exciting 
cause  and  the  susceptibility  of  the  individual  to  reflex  irritation.  In 
malarial  cases  they  occur  with  marked  periodicity,  and  sometimes  begin 
with  a  chill  and  end  with  sweating. 

Neuralgic  attacks,  when  once  developed,  are  very  apt  to  be  more  or 
less  frequent  and  obstinate  to  treatment.  If  the  attacks  are  very  severe 
and  prolonged,  the  general  health  of  the  patient  may  become  impaired. 
The  digestion  is  apt  to  be  imperfect  in  these  subjects,  the  hours  of  sleep 
cut  short,  the  ability  to  take  exercise  lessened,  the  mental  power  more 
or  less  weakened,  the  disposition  rendered  irritable,  and  many  other 
manifestations  of  the  neurasthenic  state  may  become  apparent  to  the 
patient  or  his  friends.  Personally,  I  regard  these  symptoms  as  due, 
in  most  cases,  rather  to  the  exciting  cause  of  the  neuropathic  predis- 
position than  to  the  attacks  of  pain. 

Extremely  protracted  or  very  frequent  neuralgic  attacks  tend  to 
impair  the  functions  of  the  nerve  so  affected.  In  some  instances,  we 
encounter  hj'peralgesia,  anaesthesia,  parsesthesise,  paresis,  motor  palsy, 
etc.,  as  a  result.  Twitchings,  tremor,  or  convulsive  spasms  may  also 
precede  or  accompany  severe  neuralgic  attacks.  The  trophic  functions 
of  the  nerve  will  be  shown  to  have  been  disturbed  in  case  the  skin  gets 
gloss}^  or  affected  with  eruptions,  when  the  hair  becomes  excessively 
long  or  thick,  when  the  nails  appear  to  be  altered  in  appearance,  or  when 
the  muscles  undergo  marked  atrophy. 

Diagnosis. — Sufficient  has  already  been  said  to  aid  the  reader  in 
clinically  recognizing  the  various  forms  of  neuralgia  from  each  other, 
and  in  distinguishing  typical  neuralgic  attacks  from  organic  lesions  of 
the  brain,  spinal  cord,  or  vertebrae,  which  may  induce  paroxj'sms  of  pain 
that  may  closely  resemble  such  attacks. 

The  tables  previously  given  may  prove  of  utility  in  making  these 
discriminations. 

Prognosis. — Like  other  functional  disease,  neuralgia  of  a  mild  or 
severe  tj'pe  is  seldom  if  ever  a  cause  of  death.  Still  it  must  be 
admitted  that  the  terrible  sufferings  of  many  of  its  victims  not  in- 
frequently lead  either  to  suicide  or  the  morphine  habit,  because  many 
cases  are  extremely  intractable  to  medicinal  treatment,  and  the  vital 
forces  of  the  sufferer  become  exhausted  in  consequence  of  the  recurring 
paroxj'sms  of  pain.  When  the  treatment  of  this  malady  shall  have  been 
discussed,  it  will  be  shown  conclusively,  I  think,  that  the  correction 
of  its  reflex  causes  (chief  among  which  I  would  mention  e^'e-strain) 
leads  to  happier   results   in   the   treatment   of  the   obstinate   tjpe   of 


NEURALGIA.  551 

neuralgias  than  any  of  the  remedial  agents  commonly  extolled  by 
authors  of  repute. 

Treatment. — My  views  upon  this  head  are  somewhat  at  variance  with 
those  which  have  previously  been  advanced  by  most  authors.  If  the  fact 
can  be  substantiated,  that  serious  eye-defects  exist  in  a  very  large  pro- 
portion of  those  subjects  who  sutfer  from  frequent  and  obstinate  neuralgic 
attacks,  we  must  naturally  look  to  the  eye  for  beneficial  results  which 
may  be  anticipated  from  the  relief  of  this  exciting  cause.  Both  of  these 
conclusions  are,  to  m}^  mind,  susceptible  of  proof  which  is  conclusive. 

In  the  prize  memoir  which  Dr.  Stevens  presented  before  the  Royal 
Academy  of  Belgium,  he  reports  careful  deductions  drawn  from  eight 
hundred  and  eighty-five  neuralgic  subjects  which  he  had  examined  with 
special  reference  to  the  existence  of  eye-defect  or  muscular  errors  in  the 
orbit.  The  effects  of  his  treatment  (directed  exclusively  to  the  correction 
of  such  errors)  are  shown  to  be  as  follow  in  one  hundred  consecutive 
cases  selected  from  this  large  number : — 

After  eliminating  fifteen  cases  (in  which,  for  various  reasons,  he  had 
been  unable  to  obtain  complete  records  of  the  results  of  such  treatment) 
eighty-five  cases  are  reviewed  by  this  author  in  which  the  eye  alone  was 
subjected  to  remedial  measures  for  the  relief  of  neuralgic  paroxysms  of  a 
more  or  less  persistent  and  obstinate  type.  Of  these  eighty -five  subjects, 
seventy-one,  or  83^  per  cent.,  were  absolutely  cured;  ten,  or  11|  per 
cent.,  were  markedly  benefited  ;  and  four,  or  4|  per  cent.,  were  not 
materially  relieved. 

Although  an  analysis  of  so  small  a  number  of  cases  is  not  sufficient 
to  warrant  any  positive  deductions  respecting  percentages  of  cases  in 
which  permanent  relief  may  be  expected  by  this  method  of  treatment 
when  skillfully  employed  b}'  competent  experts,  it  cannot  be  denied  that 
the  results  obtained  by  this  author  are  very  remarkable  and  entitle  his 
views  to  thoughtful  consideration.  The  total  number  of  persons  exam- 
ined by  him  for  eye-defect,  in  which  neuralgia  was  a  prominent  S3'mptom, 
was  a  very  large  one.  His  observations  go  to  show  that  it  is  a  rare 
occurrence  to  find  a  typical  case  of  neuralgia  in  which  anomalies  of 
refraction  or  a  lack  of  equilibrium  in  the  eye-muscles  does  not  exist, 
provided  the  history  of  the  case  renders  the  presence  of  organic  changes 
in  the  nerve-centres  highly  improbable. 

In  my  own  practice  I  have  examined  during  the  last  three  3'ears 
over  fifty  victims  to  neuralgia  with  reference  to  the  existence  of  eye- 
defect  as  an  exciting  cause  of  the  attacks.  I  have  found  in  almost  every 
case  satisfactory  evidence  of  anomalies,  which  I  have  deemed  of  suffi- 
cient importance  to  require  correction.  In  some,  the  correction  of  a 
latent  hyperopia  by  convex  glasses  has  been  followed  by  immediate 
relief;  in  others,  astigmatism  has  existed  to  a  high  degree  and  cylindrical 


552 


LECTURES     ON     NERVOUS     DISEASES. 


glasses  have  been  required  ;  in  a  third  class,  the  eyes  have  been  dissim- 
ilar in  reference  to  their  refractive  conditions ;  in  a  fourth  class,  the  eye 
has  given  undisputable  evidence  of  a  tendency  to  deviate  from  the  con- 
dition of  physiological  equilibrium.  Persons  of  the  fourth  class  have,  in 
the  majority  of  cases  noted  by  me,  given  no  external  evidences  of 
strabismus  or  a  tendency  thereto.  They  have,  however,  been  greatly 
benefited  in  almost  every  instance  in  respect  to  their  neuralgic  habit, 
after  partial  tenotomies  have  been  performed  upon  the  eye-muscles  for  the 
correction  of  the  abnormal  muscular  tension.  In  several  instances  I  have 
been  unable  to  persuade  a  patient  to  submit  to  surgical  relief  for  this 
defect.  Under  these  circumstances  I  have  resorted  to  prismatic  glasses. 
The  results  so  obtained  have  not  been  as  satisfactury  as  I  might  wish. 

The  following  table  will  give  to  tlie  mind  of   the  reader  a  clear 
conception  of  the  results  of  these  observations: — 

A  TABLE  SHOWING  THE  RESULTS  OF  EYE-TESTS*  MADE  IN  FIFTY  CASES 
OF  TYPICAL  NEURALGIA. 


ASTIGMATISM.                MYOPIA.  HYPEROPIA. 

EMMETROPIA. 

MUSCULAR   ERRORS. 

Myopic. 

Hyper- 
op  ic. 

Mixed. 

Biso- 
phoria. 

i:xo- 
phoria. 

Hyper- 
phoria. 

3 

5 

2 

10 

24 

9 

26 

5 

16 

Such  a  table  shows  conclusively  to  my  mind  the  necessity  of  sub- 
jecting neuralgic  subjects  to  a  systematic  method  of  eye  examination  as 
well  as  a  complete  physical  examination  (prior  to  medicinal  treatment, 
if  possible);  and  it  certainly  offers  some  forcible  suggestions  respecting 
certain  steps  which  may  be  taken  for  its  relief. 

If,  after  a  satisfactory  correction  of  all  existing  defects  so  dis- 
covered, the  neuralgic  paroxysms  persist,  further  search  should,  in  my 
opinion,  be  made  for  conditions  which  may  create  reflex  irritation; 
such,  for  example,  as  nasal,  dental,  rectal,  uterine  and  ovarian  disorders, 
which  might  have  escaped  notice  in  the  earlier  examinations  of  the 
patient. 

Probabl3^  no  nervous  malady  depends,  in  a  larger  proportion  of 
cases,  upon  reflex  disturbances  than  does  neuralgia;  hence,  neither  time 
nor  trouble  should  be  spared  in  ferreting  out  the  cause.  That  this  cause 
is  not  always  to  be  sought  for  along  the  course  of  the  affected  nerA'e,  all 
authorities  agree.  That  it  may  be  far  removed  from  the  seat  of  pain  is 
indisputable.  The  admirable  work  of  Hilton  on  "  Rest  and  Pain  "  may 
be  read  with  profit  by  those  who  seem  to  despise  scientifie  methods  of 
research,  and  who  are  ever  ready  to  grasp  at  any  new  medicinal  agent 
which  is  presented  to  them. 

*Many  of  the  cases  had  more  than  one  error.     For  example,  one  case  had  hyperopia, 
astigmatism,  esophoria,  and  hyperphoria. 


NEURALGIA.  553 

I  would  not  be  construed  as  denying  in  toto  the  influence  of  debili- 
tating influences  in  certain  cases  of  neuralgia,  such  as  malaria,  rheuma- 
tism, syphilis,  gout,  anisemia,  etc.  Any  of  these  may  constitute  a  factor 
in  certain  cases,  which  certainly  demands  our  best  efforts  at  its  removal ; 
yet,  on  the  other  hand,  our  first  duty  should  always  be  to  detect  and 
remove,  if  possible,  any  local  cause  which  may  materially  assist  in  pro- 
longing if  not  in  creating  the  neuralgic  tendency. 

If  malai'ia  exists,  quinine  in  large  doses,  arsenic,  or  Warburg's 
tincture  will  usually  aid  in  the  recovery. 

When  rheumatism  is  present,  salicylic  acid  in  some  of  its  various 
preparations,  iodide  of  j^otash,  the  carbonates  of  soda  and  potash  and 
the  oil  of  wintergreen  may  be  employed  with  good  results.  Colchicum 
may  be  given  if  gout  is  present. 

If  the  existence  of  syphilis  is  strongly  suspected,  mercury  by  the 
mouth  or  skin  and  the  employment  of  the  iodides  and  tonics  will  be 
indicated. 

In  anaemic  subjects,  it  is  well  to  give  cod-liver  oil,  iron,  arsenic,  and 
strychnia. 

Among  the  special  drugs  which  have  been  highly  recommended  for 
the  relief  of  neuralgia  ^jer  se  may  be  mentioned :  (1)  phosphorus,  in  large 
doses  every  four  hours  for  forty-eight  hours  (Thompson);  (2)  gelsemi- 
num,  in  doses  of  from  five  to  twenty  minims  for  trigeminal  neuralgia ; 
(3)  aconitia  (Duquesnil's  crj^stallized  alkaloid)  in  doses  of  one  one- 
hundred-and-flftieth  (y^o)  of  a  grain  (Seguin) ;  (4)  atropia,  by  the 
mouth  or  hypodermieall}^  in  one-fiftieth  (g^^)  grain  doses  (Anstie); 
(5)  osmic  acid,  in  a  one  per  cent,  solution  by  the  hypodermic  method 
(Eulenberg);  (6)  carbolic  acid  in  solution  of  two  parts  to  two  hundred 
of  distilled  water,  b}^  the  hypodermic  method  in  doses  of  half  a  drachm 
(Schultz);  (7)  sj-rup  of  h3'driotic  acid;  (8)  oil  of  turpentine,  in  doses  of 
a  half  ounce. 

Many  of  these  drugs  are  exceedingly  poisonous;  hence,  they  must 
be  administered  with  extreme  caution,  and  their  effects  should  be  care- 
fully noted  while  being  given  to  the  patient. 

During  the  paro^sysms  of  pain,  or  following  them,  the  following 
methods  of  treatment  may  be  tried  in  case  previous  suggestions  prove 
of  no  value  : — 

(1)  Blidering  over  the  nerve.  This  may  be  readily  done  by  holding 
chloroform  upon  the  nerve  under  a  watch-glass.  Several  spots  should  be 
blistered  simultaneously. 

(2)  The  administration  of  morphia  (by  the  mouth  or  by  means  of  a 
hypodermic  syringe).     This  is  our  main-stay  during  the  paroxysms. 

(3)  The  application  of  ice-hags  to  the  spine  (Chapman).  They  may 
be  employed  for  from  a  half  hour  to  an  hour  several  times  a  day. 


554  LECTURES   ON   NERVOUS   DISEASES. 

(4)  An  appiication  of  the  actual  cautery  over  the  affected  nerve  at 
several  points.     This  gives  less  pain  and  better  results  than  blistering. 

(5)  The  employment  of  the  '■^static  spark, ^^  or  the  positive  pole 
(anode)  of  a  galvavic  battery  over  the  seat  of  pain  (see  Section  VII). 
I  have  seen  wonderful  results  follow  these  methods  of  treatment. 

(6)  Rapid  percussion  over  the  puncta  dolorosa  by  means  of  the 
rubber  percussion  hammer.  This  will  not  be  borne  well  by  patients 
during  the  paroxysm. 

(7)  Stretching  the  affected  nerve.  Opinions  differ  respecting  the 
permanent  value  of  this  procedure. 

(8)  Acupuncture  or  electro-puncture  over  the  affected  nerve.  A 
needle  is  thrust  slowly  and  carefully  through  the  skin  and  as  near  to 
the  nerve-trunk  as  possible.  When  the  point  touches  the  nerve  (told  by 
a  peculiar  feeling  on  the  part  of  the  patient)  it  is  best  to  withdraw  the 
needle.  If  the  galvanic  current  be  employed,  care  must  be  taken  to 
prevent  electrolysis  of  the  nerve. 

(9)  Application  of  aconitia  ointment  (one  grain  to  one  ounce  of  lard) 
to  the  seat  of  pain  during  a  paroxysm.  This  is  very  dangerous  if  the 
skin  is  abraded.  It  should  be  api)lied  only  with  gloved  hands  and  kept 
away  from  the  eyes,  nose,  or  mouth. 

(10)  Continued  applications  of /io<  W'oier  to  the  part  affected.  This 
remedial  measure  is  often  of  great  benefit  during  the  paroxj'sms. 

(11)  Hot  water  may  be  injected  subcutaneously  over  the  ner\'^  (as 
a  substitute  for  morphia)  during  the  paroxysm. 


SECTION  VI. 


TOXIC  AND  UNCLASSIFIED  NERVOUS  DISEASES. 


(555) 


SECTION   VI. 

HYDROPHOBIA. 
(Rabies  in  the  Human  Race.) 

This  disease  tends  to  occur  in  the  humtm  subject  after  inoculation 
with  the  saliva  of  an  animal  affected  with  rabies.  Of  all  animals,  the 
dog  is  most  commonly  affected  with  rabies ;  although  the.  wolf  is 
frequently  so  attacked,  as  may  also  be  cats,  cows,  and  probably  other 
domestic  and  wild  animals. 

Morbid  Anatomy. — In  the  spinal  cord  of  patients  who  have  died  of  this 
condition,  as  well  as  in  the  brain,  the  blood-vessels  appear  to  be  dilated, 
and  their  walls  more  or  less  thickened.  Amyloid  degeneration  and  an 
increase  of  the  nuclei  in  the  cells  of  the  neuroglia  have  also  been  observed. 
Small  hemorrhages  may  be  occasionally  detected  in  the  cord.  According 
to  Ross,  the  median  and  central  groups  of  cells  in  the  anterior  horns  of  the 
cord  may  be  shrunken  and  atrophied;  and  the  nuclei  of  the  pneumogas- 
tric  and  spinal  accessory  nerves  in  the  medulla  may  be  similarly  affected. 

Marked  congestion  and  a  tendency  toward  hemorrhages  seem  to  be 
the  morbid  phenomena  most  generally  detected.  A  tendency  to  the 
formation  of  cavities  in  the  brain  and  the  substance  of  the  spinal  cord 
(probably  due  to  degeneration  of  the  nerve-tissue)  has  been  noted  by 
several  observers. 

It  must,  however,  be  confessed  that  we  are  as  yei  more  or  less 
ignorant  of  the  exact  character  of  the  morbid  changes  which  are 
peculiarl^^  typical  of  this  disease,  as  well  as  of  the  nature  of  the  poison 
which  seems  to  excite  it.  It  has  even  been  claimed  by  some  late 
observers  that  hydrophobia  cannot  be  regarded  as  a  distinct  disease. 

Etiology. — From  a  study  of  reported  cases,  the  saliva  of  a  rabid 
animal  seems  to  be  the  vehicle  by  which  the  poison  is  conveyed  in  most 
cases  of  hydrophobia.  Patients  who  are  bitten  upon  portions  of  the 
body  which  are  not  protected  by  the  clothing  are  apparentlj^  more 
liable  to  develop  the  symptoms  of  hydrophobia  than  when  tlie  teeth  of 
the  animal  pass  through  tlie  clothing.  It  has  not,  to  my  mind,  been 
l^ositively  proven  as  yet  that  the  poison  of  rabies  can  be  transmitted  by 
any  other  secretion  than  the  saliva;  not  even  by  inoculation  with  the 
blood  of  the  infected  animal.  The  saliva  of  hydrophobic  patients  has, 
however,  been  known  to  induce  a  similar  condition  in  other  persons, 
after  coming  in  contact  with  a  wound  or  an  abraded  mucous  surface. 
Cases  are  recorded,  also,  where  the  symptoms  of  this  disease  have 
occurred  from  a  rabid  dog  licking  the  hand  or  foce  of  a  human  being  on 
which  there  were  pimples  or  sores  (Hammond). 

(557) 


558  LECTURES   ON   NERVOUS   DISEASES. 

Symptoms. — A  wound  made  by  a  r.il)id  animal  usually  tends  to  heal 
in  the  ordinary  way.  An  interval  then  occurs,  which  is  rarely  shorter 
than  a  month,  and  probably  never  longer  than  live  ^^ears,  during  wliich 
time  the  patient  may  be  totally  free  from  any  evidences  of  ill  health.  In 
warm  climates,  hydrophobia  has  been  known  to  occur  within  a  few  days 
after  the  bite.  In  tlie  vast  majority  of  cases  recorded,  however,  the 
symptoms  have  occurred  within  a  period  of  six  or  seven  months. 

During  the  jyeriod  of  incubation,  there  may  occasionally  be  some 
unnatural  sensations  in  the  region  of  the  wound.  These  sensations 
commonly  include  shooting  pains  in  its  vicinity,  or  a  peculiar  sense  of 
distress  in  the  parts  which  the  patient  can  with  difficulty  describe.  It 
is  stated  that  the  scar  may,  occasionally,  become  more  or  less  livid.  The 
respiration  may  become  sighing  in  character  and  somewhat  irregular  as 
the  onset  of  the  attack  approaches.  There  may  also  be  a  sense  of 
oppression  or  of  constriction  in  the  chest ;  verj'  often  accompanied  b}'  a 
sense  of  anxiety  and  disturbed  sleep.  The  patient's  disposition  may 
show  a  change.  As  a  rule,  these  subjects  become  more  or  less  mood}^ 
and  irritable.  The  skin  may  be  dry  ;  and  chilly  sensations,  followed  by 
flashes  of  heat,  are  occasionally  observed. 

The  onset  of  the  attack  is  usuall}^  accompanied  by  a  sense  of 
uneasiness  in  the  epigastrium,  accompanied  by  a  feeling  of  constriction 
in  the  tliroat  and  a  difflcvilty  in  swallowing.  On  attempting  to  swallow, 
the  muscles  of  the  tliroat  are  attacked  witli  irregular  spasms.  The 
patient  cannot  be  induced  on  account  of  these  spasms  to  partake  of 
liquid  or  solid  food.  Speech  may  be  embarrassed  in  some  instances 
by  a  peculiar  and  painful  stiffness  of  the  tongue.  I  have  seen  food 
ejected  from  the  mouth  with  considerable  force,  during  an  attempt  to 
swallow,  by  one  patient  whom  I  was  called  upon  to  attend. 

The  tendency  to  spasm  and  the  reflex  excitability  of  the  patient 
soon  becomes  intensified.  The  whole  body  may  become  convulsed  from 
the  mere  suggestion  of  food  or  drink,  or  by  any  sudden  sound,  a  draught 
of  air,  a  bright  light,  the  sight  of  water,  etc.  The  patient  generall}'  shows 
physical  exhaustion  earl_y.  He  may  also  be  affected  with  trembling, 
weeping,  excessive  perspiration,  delirium,  hallucinations  and  delusions. 

The  spasmodic  phenomena  generally  tend  to  increase  in  severit}'' 
and  frequency  as  the  disease  progresses.  Vomiting  may  occur ;  and 
intense  headache  is  not  infrequent.  A  severe  pain  in  the  spine  and 
muscles  of  the  back  and  abdomen  may  develop.  The  mouth  often 
becomes  excessively  dry  and  parched.  The  saliva  may  be  very  tenacious 
and  frothy,  and  expectorated  with  difficulty.  Moistening  of  the  lips  or 
mouth  not  infrequently  tends  to  excite  convulsions.  In  one  of  the  cases 
which  I  observed  some  years  since,  the  constant  attempts  of  the  patient 
to  rid  the  mouth  of  tenacious  mucus  was  the  first  symptom  obserAcd.  It 


HYDROPHOBIA — RABIES   IN   THE   HUMAN   RACE.  559 

preceded  the  convulsions,  and  lasted  several  hours.  Within  five  hours  from 
the  time  when  I  first  saw  the  patient,  general  convulsions  of  a  severe 
character  developed  and  continued  vuiinterruptedly  until  death  occurred. 

In  three  patients  which  I  have  personally  been  called  upon  to  treat, 
I  have  never  observed  any  efforts  on  the  part  of  the  patient  to  snap  or 
bite  or  to  make  any  noise  which  could  be  compared  to  the  barking  of  a 
dog.  I  am  inclined,  therefore,  to  regard  published  statements  that  such 
symptoms  have  occurred  as  due  rather  to  the  imagination  of  the 
attendants  than  to  accurate  observation. 

The  termination  of  this  disease  is  usually  due  either  to  physical 
exhaustion,  the  frequent  convulsive  attacks,  the  loss  of  sleep,  the  in- 
ability to  take  food,  or  to  great  emotional  excitement.  It  is  stated  tliat 
laaralyses  have  been  known  to  occur  during  an  attack  of  hydrophobia, 
but  I  have  never  observed  it. 

The  temperature  of  the  body  is  markedly  elevated,  as  a  rule,  at  the 
beginning  of  the  disease,  and  is  usually  highest  at  the  height  of  the 
paroxysm  or  during  their  subsidence.  Hammond  states  that  it  may  rise 
to  110°. 

The  duration  of  the  disease  seldom  exceeds  three  days,  when  the 
symptoms  are  well  established.  Death  generally  occurs  during  a  spasm. 
It  is  stated  that  the  power  of  swallowing  sometimes  returns  before  death. 

Diagnosis. — Some  of  the  manifestations  of  hysteria  (usually  follow- 
ing severe  fright  occasioned  b}^  the  bite  of  some  animal  not  affected  by 
rabies)  may  closely  simulate  genuine  hydrophobia.  It  is  stated  that 
such  cases  can  usuall}'  be  distinguished  by  the  fact  that  the  convulsions 
do  not  invariably  follow  slight  forms  of  external  irritation,  such  as  those 
already  mentioned.  Moreover,  attempts  at  swallowing  are  not  always 
accompanied  b}-  spasmodic  action  of  the  muscles  of  the  throat.  Ham- 
mond states,  for  example,  that  "  the  h3^sterical  patient  is  apt  to  be  loud 
in  the  expression  of  apprehension,  while  the  real  hydrophobic  one, 
though  intensely  anxious  and  terrified,  endeavors  to  prevent  others 
perceiving  the  state  of  his  mind." 

The  diagnosis  of  hysteria  will  be  rendered  probable  if  the  attack 
comes  on  too  soon  after  the  bite  to  allow  of  a  period  of  incubation  ;  and 
if  the  patient  can  be  shown  to  possess  hysterical  tendencies.  Simulation 
of  hydrophobia  is  not  confined  to  females.     It  may  prove  fatal. 

An  attack  of  tetanus  may  be  confounded  with  hydrophobia.  It 
should  be  borne  in  mind,  however,  that  tetanic  spasms  are  of  the  tonic 
variety ;  that  they  atfect  chiefl}'  the  jaws  and  the  back  (not  the  throat 
primarily)  ;  that  the  mind  is  unaffected  at  all  times ;  that  atmospheric 
influences  often  predispose  to  tetanus  ;  that  the  facial  expression  shows 
less  terror  on  the  part  of  the  patient;  and  that  there  is  no  relationship 
between  the  convulsive  attacks  and  excitability  of  the  special  senses. 


560  LECTUEES   ON  XERYOUS   DISEASES. 

Prognosis.— After  hydrophobia  has  once  developed, there  are,  in  my 
opinion,  no  well-authenticated  cases  of  cure.  On  the  other  hand,  the 
prevention  of  attacks  by  the  method  of  inoculation  lately  advocated  by 
Pasteur,  seems  to  have  been  quite  well  proven  in  some  of  his  cases. 
The  bite  of  the  rabid  wolf  seems  to  be  more  uniformly  followed  by 
hydrophobia  than  that  of  the  rabid  dog.  Those  subjects  who  are  bitten 
by  a  rabid  animal  first  are  more  liable  to  develop  hydrophobia  than  are 
those  who  are  subsequently  bitten;  a  fact  that  tends  to  prove  that  the 
poison  becomes  to  a  certain  extent  exhausted,  even  in  the  rabid  animal. 
Moreover,  a  wound  which  bleeds  very  freely  is  less  liable  to  be  followed 
by  hydrophobia  than  one  in  which  the  poison  is  not  washed  away. 

Treatment. — When  any  one  is  bitten  by  a  rabid  animal,  or  even  by 
one  that  is  suspected  to  be  rabid,  the  wound  should  be  at  once  sucked  by 
the  patient ;  or,  when  not  so,  by  an  attendant  as  soon  after  the  injury  as 
possible.  There  is  no  danger  in  this  step,  if  the  mucous  membrane  of 
the  mouth  or  lips  be  not  broken  or  abraded. 

The  wound  should  also  be  thoroughly  cauterized,  either  by  caustic 
potash,  the  nitrate  of  silver,  or  by  the  ignition  of  gun-powder  in  the 
wound.  A  complete  excision  of  the  wound  may  also  be  performed 
immediately  after  the  accident,  the  part  being  tightly  constricted  after 
the  accident  to  prevent  the  circulation  carrying  the  poison  away  from 
the  Avound. 

During  the  attack  the  treatment  is  purely  symptomatic.  If  ether  or 
chloroform  be  inhaled  by  the  patient,  food  may  be  introduced  into  the 
stomach  by  means  of  a  tube.  •  Milk  is  preferable  to  any  other  form  of 
nourishment,  combined  with  alcoholic  stimulants.  Stimulants  and 
nourisliment  may  also  be  given  to  the  patient  as  enemata. 

Among  the  drugs  which  have  been  employed  during  these  attacks, 
the  following  may  be  mentioned  :  (1)  Hypodermic  injections  of  morphine 
and  atropia  during  the  paroxysms.  (2)  Large  doses  of  chloral  (twenty 
grains),  and  one  ounce  of  brandy  with  two  ounces  of  beef-jellj^  eveiy 
three  hours  as  enemata.  This  treatment  resulted  in  an  apparent  cure,  in 
the  experience  of  Broadbent.  (3)  The  tincture  of  cannabis  indica  has 
been  administered  in  doses  of  from  six  to  fifteen  drops  everj-  few  hours. 
A  continuous  application  of  the  galvanic  current  from  the  soles  of 
the  feet  to  the  forehead  during  the  attack  has  been  suggested  by  Schi- 
vardi,  of  Milan.  In  one  of  his  cases,  such  a  current  was  maintained  for 
fifty-eight  consecutive  hours  from  twenty-two  Daniel's  cells.  Life  was 
thus  prolonged  for  over  seven  days. 

The  late  researches  of  Pasteur  seem  to  have  been  attended  by  some 
extremely  favorable  results,  although  inoculation  by  his  methods  have 
not  thus  far  been  proven  to  be  an  absolute  specific  against  the  poison 
of  rabies. 


MULTIPLE  NEURITIS.  561 


MULTIPLE    NEURITIS. 


Before  we  consider  in  detail  the  various  forms  of  toxic  neuroses,  it 
may  be  advisable  to  discuss  a  condition  whicli  has  attracted  considerable 
attention  of  late,  first,  because  its  existence  seems  to  be  positively  deter- 
mined, and,  furthermore,  because  its  pathology  tends  to  shed  much  liglit 
upon  many  reported  cases  that  have  heretofore  been  probably  incorrectly 
interpreted.     I  refer  to  the  disease  now  known  as  "  multiple  neuritis." 

Under  this  term  may  be  classed  all  toxic  and  a  few  spontaneous 
cases  in  which  a  peculiar  combination  of  abnormal  motor,  sensory,  and 
trophic  phenomena  may  have  existed  during  life  in  consequence  of 
morbid  changes  in  the  peripheral  nerve-trunks. 

Morbid  Anatomy. — In  multiple  neuritis,  the  ultimate  nerve-fibres 
appear  to  undergo  certain  alterations  in  their  structure  which  vary 
somewhat  in  their  degree  and  tA'pe,  but  which  are  embraced  under  the 
general  terms  "  degeneration  "  and  "  I'egeneration.'''' 

During  the  former  process,  the  myelin  and  axis-c^-linder  of  the 
affected  fibre  becomes  at  first  segmented;  subsequently  more  or  less  dis- 
integrated and  studded  with  new  nuclei ;  and  finally  absorbed  to  a  greater 
or  less  extent,  leaving  the  sheath  comparatively  empty  save  the  presence 
of  scattered  nuclei  and  some  debris.  The  terminal  plates  in  the  muscles- 
are  simultaneously  affected.  They  tend  to  become  granular  and  to  undergo 
absorption.  It  is  also  probable  that  the  terminal  sensor}-  organs  become 
simultaneously  altered  in  their  structure;  but  the  changes  which  tliev  un- 
dergo are  less  positively  determined  than  those  in  the  muscular  apparatus. 

Should  the  process  of  regeneration  follow  after  the  extensive 
changes  already  enumerated  have  taken  place,  a  new  axis-cylinder  and 
myelin  sheath  is  slowly  formed.  This  is  probably  effected  either  by  the 
aid  of  the  nuclei  which  remain  in  the  sheath  of  Schwann  or  by  a  direct 
growth  of  the  axis-cylinder  from  the  proximal  end  of  the  nerve.  Regen- 
eration is,  as  a  rule,  an  extremely  slow  process.  From  six  to  eighteen 
months  may  be  required  to  insure  a  complete  restoration  of  a  nerve 
after  the  fibres  have  been  seriously  impaired  by  a  degenerative  process. 

In  multiple  neuritis,  the  morbid  changes  observed  in  the  nerve- 
trunks  attacked  are  so  closely  allied  to  those  which  experiment  has 
proven  to  result  from  compression  of  a  nerve-fibre  with  destruction  of 
its  axis-C3-linder — the  process  of  "  nerve-degeneration  " — that  thc}^  niay 
be  considered  as  practically  identical. 

Tlie  dependence  of  these  changes  in  mutiple  neuritis  upon  a  spinal 
lesion  seems  to  be  disproved  by  the  fact  that  the  nerves  are  not  affected 
throughout  their  entire  length,  but  only  in  their  distal  portions.  M.  A. 
Starr,  in  his  late  lectures   upon  this  condition,*  before  the  New  York 

*  Medical  Record,  February  5,  1887. 
36 


562  LECTUKES   ON  NERVOUS   DISEASES. 

Pathological  Society,  lays  great  stress  upon  this  i)()int,  as  well  as  upon 
the  fiict  tliat  the  sensory  nerves  as  well  as  the  motor  ai"e  attected  (cen- 
trifugal degeneration  of  sensory  nerves  being  never  observed  as  a  secpiel 
to  a  s})inal  lesion ).  lie  regards  the  morbid  condition  as  one  of  "  primary 
parenchymatous  inllammation  of  the  nerve-fibres." 

This  author  classifies  the  conditions  observed  in  the  nerves  of 
subjects  attacked  with  multiple  neuritis  as  of  three  types  : — 

In  the  first,  the  nerve-fibres  exhibit  no  fatty  metamorphosis.  They 
undergo  degeneration  in  their  distal  segments  and  terminal  plates 
according  to  the  normal  formulae. 

In  the  second,  the  presence  of  fatty  changes  is  very  apparent.  He 
regards  this  class  as  possibly  dependent  upon  the  pressure  exerted  upon 
the  nerve-fibres  by  the  exudation  resulting  from  a  primary  interstitial 
inflammation. 

The  third  class  recognized  by  him  is  that  originally  described  by 
Gombault  as  t^'pical  of  lead-poisoning.  It  consists  of  a  segmental 
degeneration  of  a  nerve,  with  normal  nerve-segments  being  interposed. 
He  states  that  this  condition  has  been  observed  also  in.  diphtheria  b\' 
Pitres  and  Yaillard. 

Finally  the  muscular  fibres  exhibit  an  increase  of  their  nuclei,  a 
fatty  degeneration  of  the  sarcous  elements,  and  a  progressive  atrophy 
proportionate  to  the  destruction  of  the  nerve-plates. 

Etiology. — The  man^^  conditions  which  have  been  imperfectly 
recognized  and  interpreted  in  times  past,  and  which  the  light  of  recent 
investigations  seem  to  connect  strongly  with  an  existing  multiple 
neurosis,  oflfer  some  practical  deductions  respecting  the  etiology  of  this 
morbid  condition.  There  is,  probably,  no  doubt  that  man}^  cases  which 
have  heretofore  been  reported  as  dependent  upon  a  spinal  lesion  (chiefly 
those  of  supposed  polio-myelitis  anterior),  and,  in  addition,  some  of  the 
so-called  "  functional  neuroses  "  have  at  times  been  wrongl}'  diagnosed. 
The  following  classes  of  cases  are  enumerated  by  Starr  as  particularly^ 
liable  to  be  induced  by  inflammatory  conditions  of  the  peripheral 
nerves  : — 

(1)  The '' »?n?i6/??i^er.s  "  observed  in  women  about  the  climacteric 
period  (first  described  by  I.  I.  Putnam  as  a  disease)  ;  inten-inftent 
paralyses ;  and  the  endless  train  of  obscure  subjective  si/mptoms  clin- 
ically encountered;  such,  for  example,  as  pain,  formication,  numbness, 
muscular  weakness,  which  is  not  far  removed  from  pai-esis,  tremors 
and  slight  convulsive  attack,  flashes  of  heat  and  cold,  etc. 

(2)  Toxic  Gases. — Among  these  may  be  prominently  mentioned  the 
paresis  and  tremor  encountered  in  chronic  alcoholism,  and  the  symptoms 
of  arsenic,  lead,  and  bisulphide  of  carbon  poisoning. 

(3)  Infectious  Cases. — These  include  the  results  of  diphtheria,  the 


MULTIPLE   NEURITIS. 


563 


eruptive  fevers,  tubercle,  malaria,  and  "  beri-beri  "  (an  epidemic  disease 
due  to  a  recognized  bacillus). 

(4)  Spontaneous  Cases. — These  apparently  follow  exposure  to  damp- 
ness, cold,  or  over-exertion  ;  but  their  exciting  causes  are  not,  as  yet, 
well  understood. 

Of  the  toxic  class,  alcohol  and  lead  are  the  most  prolific  causes. 
Paralysis  is,  as  we  all  know,  not  an  infrequent  result  of  chronic  alcohol- 
ism ;  and  it  is  also  a  typical  s^'mptom  of  lead-poisoning.  The  question 
whether  syphilis  can  directly  excite  multiple  neuritis  does  not  seem  to 
be  yet  well  determined. 

Symptoms. — In  multiple  neuritis,  we  are  apt  to  encounter  a  peculiar 
train  of  symptoms  in  which  are  combined  abnormal  motor,  sensor}^,  and 
trophic  phenomena.  This  clinical  fact  is  of  great  value,  since  it  may 
enable  the  observer  to  exclude  the  existence  of  a  spinal  lesion  that  might 
otherwise  be  strongly  suspected  to  exist.  In  the  main  nerve-trunks  the 
motor,  sensory,  and  trophic  fibres  are  so  intermingled  that  a  lesion  of  the 
entire  nerve  could  hardly  fail  to  involve  each,  and  thus  cause  three 
distinct  sets  of  symptoms. 

From  an  analysis  of  all  the  reported  observations  to  date,  the  deduc- 
tions made  by  Starr  relative  to  the  symptomatology  of  this  imperfectly 
understood  disease  are  of  s])ecial  interest.  The  following  tables  will 
present  the  views  of  tliis  author  in  the  fewest  possible  words  : — 

ParceslJiesice  of  various  kinds  occur  at  the  onset.    These  tend  to  dis- 
appear as  the  disease  advances. 

Occur  only  beloiv  ilbows  and  knees,  save  in  very  rare  instances. 

3Iodcraie pain.    >«'ot  continuous.    Less  severe' than  in  ataxia. 

Tenderness  in  nerves  and  muscles  is  constant.     It  renders  manipulation 
painful  and  interferes  with  massage  and  electrical  a|)plirations. 

Aniesthesia  is  rarely  complete,  but  occurs  late  in  the  disease. 

Delayed  transmission  of  jjain-sensations  and  temperature-sensations  is 
generally  observed. 

Impaired  pressure-sense  is  usually  to  be  detected. 

Muscular  sense  may  be  impaired,  but  is  often  normal. 
L  Special  senses  are  not  affected,  as  a  rule. 

f  Progressive  nniscular  weakness  and  a  sense  of  fatigue  occur  early. 
This  becomes  true  paralysis  within  the  space  of  a  few  weeks,  as  a 
I  rule. 

The  paralyzed  muscles  are  chiefly  those  which  move  the  feet  and  hands. 
I  The    distribution   of  the  paralysis  depends  on    the  nerve-trunks 

I  which  are  most  involved. 

I   Facial  muscles  and  cranial  nerves  are  not  usually  attacked. 
I   fi)>asniodic  pheiioniena  are  rarely  observed. 

I  Tendon  reflexes  are  abolished.  The  muscles  lose  their  natural  tone  and 
tend  to  atropliy. 
The  so-called  ^^  reaction  of  degeneration''''  is  detected  by  galvanic  tests, 
and  very  strong  galvanic  currents  are  required,  to  cause  muscular 
contractions  early  in  the  disease.  This  fact  is  in  contrast  with  the 
condition  observed  in  poliomyelitis. 
Faradaic  contractility  is  often  abolished  early  in  the  disease.     It  may 

not  be  entirely  lost,  however,  in  some  case's. 
The  so-called  " drop-wrist  "  and  •'  drop-foot"  are  characteristic  deform- 
ities.   They  are  very  often  encountered. 
,  The  "  claiv-hahd  "  and  various  forms  of  talipes  may  also  be  developed. 

(Edema  may  be  a  marked  and  early  symptom.    It  may  affect  the  feet, 
hands,  and  joints.    It  is  usually  temporary. 

Excessive  perspiration  of  the  feet  and  hands,  possibly  with  an  offensive 
odor. 

Glossy  skin.    This  may  develop  early  and  be  persistent.     Its  disappear- 
ance usually  indicates  regeneration  of  the  nerves. 
.  Ulcerations,  bed-sores,  and  eruptions  are  rarely  encountered. 


Sensory  Symptoms.  < 


Motor  Symptoms. 


Trophic  Symptom.s. 


564  LECTURES   ON   NERVOUS   DISEASES. 

The  onset  of  multiple  neuritis,  like  that  of  some  spinal  disease,  may 
sometimes  he  sudden  and  characterized  hy  marked  febrile  symptoms. 
The  temperature  may  occasionalh"  rise  to  103^  or  even  104.5°,  but  it 
probabl}^  has  a  lower  range,  as  a  rule.  The  pulse  is  generally'  somewhat 
accelerated,  but  it  may  rise  in  exceptional  cases  as  high  as  140.  Starr 
states  that  such  an  increase  with  marked  irregularity  probably  indicates 
degeneration  of  the  vagus  nerve. 

The  sphincters  are  never  affected  in  multiple  neuritis ;  nor  arc  the 
automatic  acts  associated  with  them. 

Dr.  H.  D.  Chapin,  of  New  York,  has  lately  reported  some  cases 
observed  among  children  in  which  the  symptoms  closely  simulated  those 
of  infantile  paralysis,  save  that  sensory  symptoms  coexisted  iviih  paralysis 
and  muscular  atrophy.  These  cases  were  surmised  by  him  (probabl}'- 
with  correctness)  to  be  examples  of  multiple  neuritis.  No  autopsy  has 
ever,  to  my  knowledge,  confirmed  such  an  observation  in  a  child, 
although  the  literature  of  this  disease  is  still  somev,hat  limited. 

A  disease  known  as  "  kakke,"  or  "  beri-beri,"  has  existed  among 
the  Chinese  for  centuries.  It  is  now  recognized  as  an  epidemic  variety  of 
multiple  neuritis,  and  its  bacillus  has  lately  been  not  only  discovered,  but 
cultivated.  E.  C.  Seguin  has  lately  published  quite  an  interesting  con- 
tribution to  this  subject,  and  M.  A.  Starr  gives  in  some  detail  the  history 
of  this  disease  in  his  admirable  lectures,  to  which  the  reader  is  referred. 
It  usually  begins  with  a  cor^za,  an  inliammation  of  the  palpebral  and 
ocular  conjunctiva,  and  some  febrile  symptoms.  Following  these  symp- 
toms, those  of  a  typical  multiple  neuritis  are  developed  more  or  less 
rapidly.     It  has  proven  to  be  at  times  a  very  fatal  type  of  epidemic. 

Diagnosis. — As  multiple  neuritis  occasionally  so  closely  simulates 
some  organic  spinal  diseases  that  a  diagnosis  is  rendered  extremely  diffi- 
cult, I  have  deemed  it  advisable  to  present  its  chief  symptoms  in  contrast 
Avith  those  of  poliomyelitis  anterior,  locomotor  ataxia,  and  diffuse  mye- 
litis. These  three  diseases  are  particular!}-  liable  to  be  confounded  with  it, 
and,  in  the  case  of  the  two  latter,  it  is  believed  that  multiple  neuritis  can 
occur  as  a  complication.  According  to  the  statements  of  Levden,  who 
disagrees  with  many  other  observers,  the  existence  of  diffuse  mj-elitis 
without  a  coexisting  multiple  neuritis  is  rendered  highly  Improbable.  It 
is  certain  that  the  symptoms  of  these  two  diseases  present  many  points 
of  similarity  which  might  easily  mislead  any  one  in  making  a  diagnosis. 

In  connection  with  locomotor  ataxia,  there  seems  to  be  a  growing 
tendency  among  French  neurologists  to  regard  the  serious  trophic 
disturbances  which  are  occasionall}'  encountered  during  the  final  stages 
of  tabes  as  dependent  upon  a  complicating  multiple  neuritis. 

The  table  opposite  may  aid  the  reader  somewhat  in  making  a 
differential  diagnosis  ; — • 


MULTIPLE  NEURITIS. 


565 


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566  LECTURES   ON   NERVOUS   DISEASES. 

Prognosis. — A  complete  removal  of  the  toxic  condition  which  gen- 
erally constitutes  the  uiulerlyiiig  cause  of  multiple  neuritis  tends,  as  a 
rule,  to  aid  in  establishing-  a  more  or  less  complete  regeneration  of  the 
nerves.  Time  is  an  essential  factor  in  this  step,  however ;  the  process  of 
regeneration  often  extending  over  a  period  of  from  two  to  sixteen  months. 

In  the  majority  of  non-epidemic  cases,  a  complete  recovery  may 
reasonably  be  anticipated.  In  epidemics,  the  proportion  of  recoveries  is 
less.  The  evidences  of  a  commencing  regeneration  are  shown  first  in  a 
stationary'  condition,  followed  by  an  amelioration  of  the  symptoms  and  an 
alteration  in  the  galvanic  formulse  of  the  nerves  and  muscles  att'ected,  and 
a  return  of  faradaic  contractility.  The  cases  which  offer  the  most  serious 
prognosis  are  those  which  are  due  to  an  excessive  toxic  condition,  and, 
according  to  Starr,  those  in  which  the  disease  "  begins  with  great 
suddenness,  advances  rapidl}^,  and  involves  the  phrenic  and  pneumo- 
gastric  nerves." 

Comiilications  may  occasionally  arise  in  connection  with  multiple 
neuritis  and  materiall}'  modify  the  prognosis.  Among  those  to  be 
anticipated,  the  following  may  be  mentioned  :  (1),  myelitis  ;  (2),  cerebral 
and  gastro-intestinal  symptoms  (chiefly  in  alcoholic  patients)  ;  (3),  ataxia ; 
(4j,  paralysis  of  the  cranial  nerves  (chiefly  in  diphtheritic  subjects)  ;  and 
(5),  where  tuberculosis  or  syphilitic  lesions  develop  in  the  nerve-centres 
or  viscera. 

Treatment. — The  pains  should  be  controlled  by  a  judicious  use  of 
hot  or  cold  applications,  and  also  by  raorphine,  whenever  excessively 
severe.  The  tenderness  of  the  limbs  often  renders  the  employment  of 
evaporating  lotions  of  real  service.  The  internal  administration  of  the 
salicylate  of  soda  in  large  doses  is  said  to  exert  a  specific  action  upon 
the  disease  in  its  early  stages.  Starr  recommends  also  the  emplo3'ment 
of  cold  douches,  lotions  of  carbolic  acid  (5  per  cent.),  enveloping  the  limbs 
in  cotton  and  oil-silk,  and  rubbing  of  the  limbs  with  cocoanut  oil. 

The  suggestions  previously  made  in  relation  to  the  treatment  of 
syphilis  (p.  291),  and  those  which  are  subsequently  given  relative  to  the 
treatment  of  lead-,  arsenic-,  and  alcohol-poisoning,  are  applicable  to 
certain  t^pes  of  this  disease.  In  alcoholic  patients,  every  precaution 
should  be  taken  to  prevent  the  patient  from  surreptitious  indulgence. 

In  chronic  cases,  strychnia  (in  doses  of  ^^  ^^  ^^  of  a  grain),  phos- 
phorus (chiefly  in  some  preparation  of  the  hyperphosphites),  iron,  and 
Fowler's  solution  of  arsenic  may  prove  of  benefit  whenever  the  patient 
is  anaemic  or  exhibits  low  vitality.  It  is  also  well  to  stimulate  the 
circulation  of  the  limbs  by  alternating  hot  and  cold  douches,  warm 
baths  at  night,  systematic  daily  massage,  and  electrical  applications. 

Respecting  electrical  iipplications,  the  employment  of  galvanism  or 
static  electricity  is  often  rendered  imperative  when  faradaic  contractility 


CHRONIC   LEAD-POISONING.  567 

is  abolished  b}"  the  degeneration  of  the  affected  nerves.  This  subject 
will  be  discussed  more  fully  in  a  subsequent  chapter.  The  reader  is 
also  referred  to  the  tests  for  nerve-degeneration  given  on  page  189. 

CHRONIC   LEAD-POISONING. 
(Pluvibism — Saturnine-poisoning.) 

Lead  may  be  taken  into  the  system  (1),  b}'  means  of  the  skin  in 
certain  occupations;  (2),  by  the  drinking  of  water  which  has  remained 
too  long  in  lead  pipes  or  tanks;  or  (3),  by  its  inhalation  in  tlie  form  of 
dust.  A  case  of  a  peculiar  character  came  under  m^^  observation  some 
years  since,  where  a  child  swallowed  a  lead  to}^  and  was  subsequently 
affected  by  recurring  attacks  of  lead-poisoning.  It  eventually  proved  fatal. 

Etiology. — In  some  of  the  manufacturing  processes,  the  workmen 
are  constantly  exposed  to  the  deleterious  effects  of  lead.  Thus,  for 
example,  the  manufacture  of  paint,  of  colored  papers,  of  rubber,  of 
enamel,  etc.,  predisposes  the  workmen  employed  to  this  disease,  Manj- 
of  our  foods  which  are  preserved  in  tin  cans  maj^  become  impregnated 
with  lead.  A  child  of  one  of  ni}^  intimate  friends  was  thus  fatally 
poisoned.  The  drinking-water  of  suburban  residences  is  particnlarl}' 
liable  to  become  poisonous  in  case  it  is  allowed  to  stand  during  the 
winter  months  in  lead  pipes  or  in  cisterns  lined  with  lead.  Some  of  the 
mineral  w\aters,  as  well  as  ale,  beer,  etc.,  are  liable  to  contain  lead  from 
being  stored  in  improper  receptables. 

Morbid  Anatomy. — The  morbid  changes  observed  in  all  toxic  paral- 
yses are  closely  allied  to  those  of  multiple  neuritis.  The  nerves  which 
supply  the  paral^'zed  muscles  frequently  undergo  atroph}^  and  degener- 
ation. 

In  the  spinal  cord,  changes  have  been  observed  in  the  cells  which 
compose  the  anterior  horns. 

The  extensor  muscles  of  the  upper  extremities  and  the  vmsculo-sjnral 
nerve  are  most  frequently  affected  when  lead  is  the  exciting  cause. 

The  affected  muscles  exhibit  a  marked  increase  of  nuclei  of  the 
sarcolemma,  a  gradual  wasting  of  the  muscular  fibres,  an  increase  of  the 
interstitial  tissue,  and  occasionally  an  increase  of  fatty  tissue.  Accord- 
ing to  some  authors,  the  changes  in  the  muscles  are  primar}^;  those  of 
the  nerves  and  the  spinal  cord  lieing  developed  after  the  muscles.  It  is 
maintained  bj^  others  that  the  peripheral  nerves  first  exhibit  a  degenera- 
tive form  of  atrophy. 

In  some  instances,  the  brain  has  been  found  to  exhibit  induration 
and  atrophy ;  and  also  marked  evidences  of  inflammation  and  softening. 

Symptoms. — The  effects  of  lead-poisoning  maj^  be  indicated  by  the 
following  conditions:  (1)  Lead-colic;  (2)  lead-paralysis;  (3)  brain 
symptoms;  (4)  lead-anajsthesia ;  (5)  lead-hypersesthesia. 


568  LECTURES   ON   NERVOUS   DISEASES. 

Lead-colic. — The  presence  of  \rM\\  of  a  very  severe  character  in  the 
region  of  tlie  umbilicus,  the  epigustriuui,  tlie  liypogastrium,  or  tlie  entire 
abdomen,  should  always  give  rise  to  a  suspicion  of  lead-poisoning,  in  case 
the  abdomen  is  found  to  be  unusually  hard  or  retracted  during  the  height 
of  the  paroxysm.  Such  attacks  are  usually  accompanied,  moreover,  by 
nausea  and  vomiting  and  the  most  marked  constipation. 

The  pain  is  generally  relieved  by  firm  and  uniform  pressure.  The 
duration  of  the  paroxism  varies  from  a  few  minutes  to  an  hour  or  more. 
The  parox3-sras  tend  to  return,  and  are  generall}'  most  severe  during  the 
night.  Patients  usually  lie  upon  the  abdomen  or  press  firmly  upon  it 
with  their  hands. 

The  distress  of  the  patient  during  a  paroxj'sm  is  intense,  and  the 
respiration  is  somewhat  more  frequent  than  normal  and  often  quite 
irregular.  The  pulse  is  seldom  accelerated.  This  form  of  lead-poisoning 
is  particularly  liable  to  occur  in  painters. 

Lead-parah/sis. — This  is  one  of  the  later  symptoms  of  lead-poisoning. 
A  blue  line  on  the  gums  and  more  or  less  frequent  attacks  of  lead-colic 
usually  precede  development.  An  excessive  use  of  alcohol  and  the 
persistent  use  of  the  muscles  of  the  forearm  are  said  to  predispose 
to  it. 

As  a  rule,  this  form  of  paralysis  develops  gradually.  In  exceptional 
cases,  however,  a  sudden  onset  may  be  observed.  The  muscles  supplied 
by  the  musculo-spiral  nerve  are  more  often  attacked  than  those  of  the 
lower  limbs,  the  back,  or  those  of  the  chest.  It  may  occur  in  one  arm 
or  in  both.  The  common  extensor  of  the  fingers  and  the  extensor  to  the 
wrist,  little  finger,  and  index  finger  are  usually  attacked  first.  The 
muscles  of  the  "  ball  of  the  thumb  "  and  the  first  interosseous  maj"  be 
involved  later.  The  triceps  usuall}'  escapes.  In  the  lower  limbs,  the 
muscles  of  the  peroneal  group  are  usually  first  attacked. 

The  onset  of  this  form  of  paralj'sis  is  usually  accompanied  by  a 
slight  numbness  and  a  tendenc}'  to  tremor  in  the  muscles  artected.  The 
patient  notices  a  progressive  loss  of  strength  in  one  or  both  hands,  and 
a  marked  difficulty  in  extending  the  wrist  and  the  fingers.  The  circula- 
tion in  the  atfected  limbs  is  imperfect,  and  the  joints  may  be  more  or  less 
painful  and  swollen. 

The  "  reaction  of  de(ieneration  "  develops  in  the  paralyzed  muscles. 
Faradaic  irritability  of  the  muscles  is  gradually  abolished. 

Fibrillar}'  contractions  in  the  aflected  muscles  are  often  observed. 

The  cutaneous  and  tendon  reflexes  are  decreased  or  abolished  in  those 
regions  where  the  muscles  are  affected. 

The  peculiar  cachexia  can  generally  be  ol)served.  The  disease 
tends  to  run  a  chronic  course.  Occasionally  relapses  are  observed, 
■without  any  fresh  exposure  to  lead. 


CHRONIC   LEAD-POISONING.  569 

Trophic  disturbances  raa,y  occasionally  be  noted,  chiefly  in  the 
form  of  an  enlargement  of  the  sheaths  of  the  tendons  and  of  the 
phalanges. 

Brain  Symptoms. — These  are  comprised  under  the  condition  known 
as  "  lead-encejjhalopathy .'''' 

The  symptoms  of  this  condition,  if  of  a  mild  character^  include 
dizziness,  headache,  an  abnormal  irritability  or  depression,  an  incapabil- 
ity for  mental  exertion,  disturbed  digestion,  tremors  in  the  hands,  and 
disturbed  sleep.  The  tremulous  condition  of  the  hand  exists  when  the 
limbs  are  at  rest ;  but  it  is  greatly  aggravated  whenever  the  muscles  are 
actively  employed. 

When  this  condition  is  of  a  more  severe  type^  delirium,  convulsions, 
and  coma  may  develop.  The  convulsive  attacks  ma}^  closely  resemble 
those  of  genuine  epileps}-,  Kepeated  convulsions  of  this  type  may 
occasionally  follow  each  other. 

If  coma  develops,  the  loss  of  sensibility  is  only  partial. 
The  breath  usually  has  a  peculiar  odor.     As  is  noticed  in  all  severe 
forms  of  lead-poisoning,  the    complexion  of  these  patients  is   usually 
pale,  and  marked  emaciation  is  present. 

Lead-anaesthesia. — This  commonly  aftects  the  optic  nerve,  and  causes 
more  or  less  complete  blindness.  It  may  occasionally  be  observed  both 
in  the  skin  and  muscles  of  the  extremities  and  the  trunk.  Its  onset  is 
usually  rapid.  Hammond  states  that  it  reaches  its  height  in  a  few  hours. 
Lead-hypersesthesia. — Lead-poisoning  may  create  pains  in  the  limbs, 
chiefly  in  the  flexures  of  the  joints  of  the  leg.  The  groin  and  the  pop- 
liteal space  are  generally  att'ected  when  the  leg  is  attacked  ;  and  the 
axilla  and  bend  of  the  elbow,  when  the  upper  extremity  is  attacked. 

Thuse  p)ains  occur  in  paroxysms  and  appear  to  be  excited  by  move- 
ments, exposure  to  cold,  or  marked  emotional  disturbances.  They  are 
usually  relieved  by  firm  and  uniform  pressure  over  the  seat  of  the  pain. 
There  is  no  redness,  swelling  or  heat  in  the  affected  region.  The  char- 
acter of  the  pain  presents  many  variations.  It  may  be  an  ache,  a  sense 
of  heat,  or  a  sharp  twinge  of  acute  pain. 

The  use  of  cosmetics  may  be  the  cause  of  lead-poisoning.  From 
such  a  cause,  the  muscles  of  the  face  may  be  paralyzed ;  an  occurrence 
which  is  extremely  rare  under  other  circumstances.  The  use  of  certain 
hair-dyes  containing  lead  is  said  to  result  in  lead-poisoning  in  occasional 
instances. 

Diagnosis. — The  diagnosis  of  lead-poisoning  is  usually  not  difficult. 
A  careful  investigation  of  the  case  will  show  that  the  patient  has  l)een 
exposed  to  the  poisonous  action  of  lead  in  some  way.  The  muscles 
aflfected  by  paralysis  are  so  often  those  which  are  supplied  by  the 
musculo-spiral  nerve  (with  the  exception  of  the  supinators)  that  it  can 


570  LECTUEES   ON   NERVOUS   DISEASES. 

scarcely  be  confounded  with  a  local  affection  involving  that  nerve; 
because  the  supinators  would  in  that  case  be  paralyzed  as  well  as  the 
extensors,  and  sensory  disturbances,  moreover,  would  probably  coexist 
with  the  motor  symptoms. 

In  peripheral  palsy  of  the  musculo-spiral  nerve,  a  local  cause  can 
generally  be  demonstrated,  such  for  example  as  a  traumatism,  sleeping 
upon  the  arm  so  as  to  affect  that  individual  nerve,  crutch-injury,  etc. 
It  is  stated  that  Russian  coachmen  frequently  get  paral3'sis  of  this  nerve 
from  winding  the  reins  about  the  arm  while  thej'  fall  asleep  upon  the  box. 

The  history  of  the  patient  will  usually  show  that  attacks  of  lead- 
colic  have  existed  before  the  paralysis  appeared ;  and  the  appearance  of 
the  gums  may  also  indicate  the  existence  of  the  poisonous  effects  of  lead 
in  the  system.     Lead  ma^-  almost  invariably  he  detected  in  the  urine. 

Poliomyelitis  may  in  some  cases  resemble  lead  paral3'sis.  The  dis- 
tribution of  the  paralysis  is,  as  a  rule,  very  different  from  that  which  is 
due  to  lead  ;  and,  in  the  history  of  the  patient,  nothing  can  be  detected 
which  points  toward  a  toxic  condition.  The  urine  would  also  be  found 
free  from  lead-salts. 

Acute  cerebrospinal  meningitis  may  be  recognized,  from  the  brain 
s^'mptoms  which  follow  lead-poisoning  in  some  cases,  b}'  the  fact  that 
there  is  a  marked  rise  in  temperatiu-e  in  the  former,  while  there  is  no 
increase  in  temperature,  as  a  rule,  when  the  symptoms  are  referable  to 
lead. 

Prognosis. — Unless  the  patient  takes  precautions  to  prevent  subse- 
quent poisoning  by  this  agent,  relapses  are  very  liable  to  occur.  Even 
without  renewed  poisoning,  relapses  are  not  infrequent.  The  prognosis 
depends,  in  individual  cases,  upon  the  extent  of  the  paralysis  and  the 
reactions  of  the  affected  muscles  to  electric  stimulation.  If  the  muscles 
shall  have  entirely  lost  their  excitability  to  the  faradaic  current,  a  com- 
plete recover}'  cannot  reasonabh'  be  expected  inside  of  several  months, 
if  at  all. 

The  brain  symptoms  which  sometimes  accompany  plumbism  are  the 
most  serious  of  its  clinical  manifestations.  In  these  cases  death  may 
occur. 

Under  proper  treatment,  I  have  never  observed  a  fatal  result  from 
lead-poisoning. 

Treatment. — Whenever  a  patient  is  known  to  be  exposed  to  the 
poisoning  influence  of  lead,  it  is  the  duty  of  the  ph^'sician  to  warn  him 
of  his  danger  and  of  the  serious  consequences  which  are  apt  to  follow. 
His  urine  should  be  examined  for  lead  from  time  to  time.  If  an 
attack  of  lead-colic  should  occur,  the  patient  should  at  once  remove 
himself  from  such  a  danger ;  even  if  the  attack  should  3'ield  promptly 
to  treatment. 


AKSENIC-PAEALYSIS.  571 

In  the  construction  of  factories  where  lead  is  employed  too  much 
stress  cannot  be  laid  u})on  the  proper  protection  of  the  workmen 
employed.  Again,  patients  who  are  known  to  be  addicted  to  the  use  of 
cosmetics  and  hair-dyes  should  be  instructed  to  discontinue  their  use  in 
case  they  are  found  to  contain  lead. 

The  internal  administration  of  the  iodide  of  'potash.,  in  doses  of  from 
ten  to  fifteen  gi'ains  three  times  a  day,  has  been  shown  to  set  free  the 
lead  that  is  in  the  system,  by  causing  a  decomposition  of  the  albuminates 
with  which  that  metal  becomes  united.  The  iodide  of  lead  is  thus 
formed,  and  this  salt  is  rapidly  excreted  from  the  system,  chiefly  by  the 
kidne3'S.  Under  its  use,  a  disappearance  of  the  blue  line  around  the 
gums  will  usually  take  place  rapidly. 

When  there  is  great  debility  the  admiyiistration  of  iron.,  quinine,  or 
strychnia,  may  often  be  advisable. 

The  hygienic  surroundings  of  a  patient  suffering  from  lead-poisoning 
should  be  carefully  regarded,  and  nutritious  and  easily  digested  food 
should  be  given. 

Attacks  of  lead-colic  frequently  demand  the  use  of  morphine,  pref- 
erably by  the  hypodermic  syringe,  to  control  the  pain.  An  occasional 
purgative  may  also  be  given  with  advantage,  preferably  castor  oil. 

Warm  baths,  particularly  sulj)hur  baths,  are  said  to  greatly  assist 
the  recover^'  of  the  patient :  they  should  be  giA-en  for  from  fifteen  to 
thirty  minutes  daily. 

Lead-paralysis  is  best  treated  by  the  use  of  the  faradaic  or  galvanic 
currents.  The  latter  current  is  particularly  indicated  as  long  as  the 
former  fails  to  produce  muscular  contraction.  The  applications  should 
be  made  daily  for  a  duration  not  to  exceed  five  minutes. 

When  galvanism  is  employed,  a  labile  application  of  the  cathode,  with 
the  anode  upon  the  nape  of  the  neck  or  the  sternum,  jdelds  the  best  results. 

I  have  employed  the  static  spark  to  these  muscles  with  very  marked 
benefit  in  many  cases.  The  instrument  must  be  of  considerable  power 
if  employed  for  this  purpose. 

Frictions  to  the  pai't,  systematic  massage,  and  passive  exercise  are 
valuable  adjuncts  to  electrical  applications. 

Mechanical  appliances  may  be  emplo^'ed  to  the  paralj'zed  limb,  with 
advantage  to  the  patient,  in  some  instances. 

AESENIC-PAEALYSIS. 

This  form  of  paral3^sis  generally  occurs  after  acute  poisoning.  It 
usually  develops  rapidly,  and,  like  other  toxic  paralyses,  is  probably  to 
be  attributed  to  a  multiple  neuritis  which  has  been  induced. 

It  may  be  distinguished  from  lead-paralysis  by  the  fact  that  the 
lower  limbs  are  more  apt  to  be  affected  than  the  upper,  by  the  rajiid 


572  LECTURES   ON  NERVOUS   DISEASES. 

atrophy  which  occurs  in  the  muscles  paralyzed,  and  by  the  presence  of 
marked  sensory  disturbances. 

Violent  pains  usually  precede  the  parah'sis  and  atrophy.  Among 
the  sensor}'^  disturbances  noticed,  numbness^  analgesia^  and  formication 
are  prominent. 

Symptoms  of  incoordination  of  movement  have  been  observed  to 
follow  arsenical  poisoning. 

The  condition  of  the  reflexes,  and  the  alteration  in  the  electrical 
excitability  of  the  muscles  are  similar  to  those  observed  in  lead-poison- 
ing. 

Treatment. — This  is  similar  to  that  already  described  in  connection 
with  plumbism. 

PHOSPHORUS-PARALYSIS. 

This  form  of  poisoning  may  be  of  the  acute  or  the  chronic  type. 
In  connection  with  both  forms,  monoplegia,  paraplegia,  and  peripheral 
paralysis  have  been  observed. 

In  the  paralyzed  parts,  all  forms  of  subjective  sensory  disturbances 
(paraesthesiae,  see  p.  354)  and  pain  may  be  experienced  by  the  patient. 

Little  is  positively  known  regarding  the  morbid  changes  which  are 
induced  in  the  nerves  or  nerve-centres  by  arsenic  or  phosphorus.  Tlie 
evidences  of  multiple  neuritis  are  generally  detected  in  all  forms  of 
toxic  paralyses.  Experimentation  made  upon  dogs  by  Yulpian  seem  to 
show  that  changes  in  the  peripheral  nerves,  as  well  as  in  white  matter 
and  anterior  horns  of  the  spinal  cord,  take  place. 

The  history  of  the  case  will  usually  suffice  for  a  diagnosis.  The 
treatment  of  the  sj-mptoms  is  not  unlike  that  employed  in  lead-poisoning, 

ALCOHOLIC   POISONING. 

{A Icoholism — Delirium  Tremens.) 

The  ingestion  of  a  large  quantity  of  alcohol  produces  effects  which 
are  modifled  b}'  special  idiosyncrasies  of  the  patient,  as  well  as  b^^  the 
habits  of  the  patient  in  respect  to  alcohol. 

ACUTE    ALCOHOLISM. 

The  condition  which  is  here  described  does  not  include  simple  intoxi- 
cation, which  is  too  often  seen  not  to  be  recognized,  but  rather  a  state 
which  is  induced  by  the  poisonous  effects  of  very  large  quantities  taken 
at  once  or  gradually  established  after  a  prolonged  and  excessive 
indulgence. 

"  Delirium  tremens,"  or  acute  alcoholic  poisoning  is  most  commonly 
observed  after  a  prolonged  debauch,  or  after  an  excessive  indulgence  in 
alcoholic  liquors  l)y  one  who  has  been  an  habitual  drinker  for  a  sufficient 


ACUTE   ALCOHOLISM.  573 

length  of  time  to  seriously  undermine  the  general  health.  It  is  claimed 
that  it  may  also  occur  in  habitual  drinkers  from  the  sudden  cessation  of 
the  habit.  This  fact  is  probably  attributable  (if  it  really  ever  occurs)  to 
a  condition  of  S3'stem  which  is  so  thoroughly  under  the  toxic  influence 
of  alcohol  that  its  ingestion  is  no  longer  passible,  because  it  is  refused 
by  the  stomach.  If  this  view  be  a  correct  one,  the  development  of  alco- 
holismus  is  due  rather  to  the  depressed  systemic  condition  than  to  the 
stoppage  of  alcohol.  It  is  well  known  that  many  habitual  drinkers  eat 
sparingly  and  irregularly,  sleep  but  little,  and  undergo  more  or  less 
exposure.  These  circumstances  are  probabl}^  conducive  to  a  condition 
of  physical  weakness,  of  which  this  disease  is  but  a  manifestation. 

Symptoms. — Preceding  the  actual  onset  of  an  attack,  it  is  not 
uncommon  to  observe  more  or  less  tremor  of  the  hands  and  tongue,  and 
a  marked  unsteadiness  in  the  upper  limbs  when  voluntar}-  movements 
are  attempted.  The  muscles  of  the  lower  limbs  and  trunk  are  sometimes 
similarly  atl'ected,  causing  an  unsteadiness  of  gait.  As  a  rule,  these 
phenomena  are  most  marked  on  arising,  and  they  tend  to  disappear  to  a 
greater  or  less  extent  after  the  patient  has  taken  several  drinks  to 
develop  an  appetite  for  breakfast.  The  feebleness  of  gait  in  some  of 
these  patients  and  the  unsteadiness  of  the  hands  and  upper  limbs  are 
too  frequently  spoken  of  by  such  patients  as  "  nervousness."  Respecting 
this  point,  Hammond  very  aptly  remarks  :  "  From  this  feebleness,  or 
paresis,  the  distance  to  paralysis  is  not  great."  It  may  indicate  the 
beginning  of  multiple  neuritis. 

Prior  to  the  onset  of*  an  attack  vomiting  is  often  a  prominent  symp- 
tom. The  patient  may  also  exhibit  sudden  startings  and  a  peculiar 
watchfulness  and  distrust  of  his  surroundings.  Morbid  fears  of  various 
kinds  may  be  developed.  The  expression  may  be  markedly  altered,  and 
the  eyes  may  be  peculiarly  w^atery  or  red.  Perspiration  is  sometimes 
excessive.  The  fingers  may  be  observed  in  some  instances  to  be  more 
or  less  constantly  employed  in  some  aimless  pursuit.  Finally  vertigo, 
headache,  and  confusion  of  ideas  may  be  encountered  in  such  patients. 

As  the  onset  ajjproaches,  these  symptoms  tend  to  increase  in  inten- 
sity, and  other  morbid  phenomena  appear.  The  face  of  the  patient  gives 
evidence  of  more  or  less  alarm.  This  is  frequently  due  to  the  fact  that 
they  experience  illusions,  hallucinations,  and  delusions  which  are  of  an 
alarming  type.  Many  cases  of  suicide  have  occurred  among  this  class 
of  patients  in  their  endeavor  to  escape  from  some  horrible  object  which 
they  believe  is  pursuing  them.  Thej'  see  demons,  snakes,  lizards,  cats, 
etc.,  about  the  room  and  menacing  their  safety.  Sleep  is  no  longer 
possible  on  account  of  these  visions.  The  patient  is  liable  to  become 
more  or  less  uncontrollable  and  to  form  bitter  dislikes  toward  his  friends, 
relatives,  or  attendants      The  temperature  is  generally  elevated,  although 


574  LECTUKES  ON  NERVOUS  DISEASES. 

the  body  may  be  bathed  in  a  profuse  perspiration.  The  pulse  is  markedly 
accelerated,  snuvll,  and  weak.  The  bowels  are  constipated.  The  patient 
talks  incessantly  concerning  various  illusions  or  delusions  which  disturb 
him.  The  pupils  are  small,  and  the  retina  may  be  congested  in  the  region 
of  the  disk.  Convulsions  "sometimes  occur,  usually  of  the  epileptiform 
character.  When  these  are  developed,  they  are  liable  to  be  frequently 
repeated.  They  are  a  grave  symptom,  and  death  may  occur  in  one  of 
these  paroxysms. 

The  duration  of  such  an  attack  varies  from  three  days  to  a  week  or 
more. 

When  the  attack  produces  dangerous  exhaustion,  a  low  muttering 
delirium  takes  the  place  of  the  loud  ravings  of  the  patient.  The  fingers 
pick  aimlessly  at  the  bed-clothes.  Gi'aduall}-  the  pulse  becomes  almost 
too  rapid  to  count  and  very  weak.  A  state  of  coma  develops.  The 
patient  then  either  gradually  sinks  or  dies  in  a  convulsive  attack. 

CHRONIC  ALCOHOLISM. 

This  form  of  alcoholic  poisoning  differs  from  the  acute  chiefly  in 
the  absence  of  a  marked  onset  and  the  characteristic  phenomena  of 
delirium  tremens  already  described.  In  cities,  it  is  more  often  encoun- 
tered among  the  idle  and  wealthy  classes  than  the  acute  form.  These 
are  prone  to  indulge  in  alcohol  to  great  excess  during  the  hours  spent 
at  the  club,  the  gaming  table,  and  social  festivities. 

Symptoms. — The  manifestations  of  chronic  alcoholism  differ  in 
individuals.  It  may  be  well  to  describe  them  under  the  following 
heads:  (1)  That  in  which  tremor  predominates.  (2)  The  anaesthetic 
type.  (3)  The  convulsive  t3-pe.  (4)  The  parahtic  type.  (5)  The 
mental  type. 

Alcoholic  Tremor. — This  may  precede  an  attack  of  delirium  tremens 
in  occasional  instances.  It  has  been  already  described,  therefore,  among 
the  premonitory  symptoms  which  occasionally  indicate  the  approaching 
onset  of  the  acute  variety  of  alcoholism.  It  chiefly  affects  the  hands, 
and  is  liable  to  be  accompanied  by  unsteadiness  of  the  legs  and  trunk — 
particularly  in  subjects  Avho  are  victims  to  chronic  alcoholismus.  On 
account  of  this  tremor,  such  patients  are  often  prone  to  drop  things 
from  their  grasp  unless  they  constantly  watch  the  object.  When  their 
eyes  are  withdrawn,  the  grasp  is  unexpectedly  relaxed. 

The  muscles  of  the  legs  and  trunk  suffer  from  more  or  less  paresis^  as 
the  condition  progresses.  I  have  repeatedlv  known  such  patients  to  lose 
in  time  their  ability  to  walk  without  the  aid  of  an  attendant.  For  a 
while  they  get  along  by  the  support  of  a  heavy  cane. 

Vertigo  and  dimness  of  vision  are  sometimes  experienced  as  the 
result  of  chronic  alcoholism.     Various  disturbances  of  sensation  may  be 


CHKONIC  ALCOHOLISM.  5/5 

developed,  such  as  numbness,  formication,  analgesia,  etc.  These  will  be 
discussed  under  the  next  variety. 

The  paresis  and  abnormal  sensory  phenomena  are  probably  to  be 
attributed  to  morbid  changes  in  the  peripheral  nerves.  In  many  cases 
of  this  type,  the  pathological  evidences  of  multiple  neuritis  are 
unmistakably  present. 

The  Anaedhetic  Type. — Occasionall}^,  from  the  very  onset  sensibility 
maj^  be  perverted  or  entirel}'  lost  in  chronic  alcoholism. 

The  presence  of  anesthesia  may  be  limited  to  one  lateral  half  of 
the  body  (hemianaesthesia).  Hammond  speaks  of  this  condition  as 
peculiarly  characteristic  of  chronic  alcoholism, — a  view  which  he  states 
to  be  in  accord  with  the  observations  of  Magnan  and  Virenque. 

In  addition  to  this  loss  of  sensation,  the  same  observer  states  that 
the  sight  of  one  eye.  the  hearing  of  one  ear,  and  the  fnnctions  of  one 
nostril  and  one  lateral  half  of  the  tongue  are  often  abolished.  He 
mentions  one  case  cited  by  Magnan,  in  which  the  sensibility  of  the 
cornea  was  totally  lost  in  one  ejQ. 

As  a  result  of  anaesthesia,  the  patient  has  imperfecjt  conceptions  of 
the  ''  feel "  of  objects ;  and  the  sense  of  pain  may  be  totally  lost  both  in 
the  skin  and  the  muscles.  These  patients  may  thus  be  rendered  personall}' 
unconscious  of  tests  made  with  a  view  to  determine  their  appreciation 
of  touch,  pain,  or  temperature. 

A  more  or  less  marked  loss  of  motor  power  invariably  accompanies 
the  abolition  of  sensation. 

The  Convulsive  2ype. — It  is  not  uncommon  to  observe,  in  patients 
who  are  suffering  from  chronic  alcoholism,  convulsive  seizures  of  an 
epileptiform  character.  These  may  occur  as  early  symptoms,  or  they 
may  follow  some  of  the  other  symptoms  already  described.  As  a  rule, 
they  are  usually  accompanied  b}^  marked  and  permanent  derangements 
of  sensibility,  and  more  or  less  paresis  during  the  intervals  between  the 
convulsive  attacks. 

The  convulsive  seizures  may  or  may  not  be  accompanied  by  loss  of 
consciousness. 

According  to  Huss,  the  frequency  of  convulsive  attacks  tends  to 
diminish  as  the  condition  of  chronic  alcoholism  increases. 

I'he  Paralytic  Form. — In  connection  with  the  previous  types  of 
chronic  alcoholism,  paresis  has  been  mentioned  as  a  symptom  wiiich  is 
generally  present.  In  some  cases  the  loss  of  motility  progresses  to  such 
an  extent  as  to  render  locomotion  impossible  and  to  constitute  true 
paralysis.  One  very  marked  case  of  this  character  has  come  under  my 
observation. 

In  connection  with  the  paralysis  of  the  limbs,  the  muscles  of  the 
eye  are  occasionally  observed  to  suffer  from  paralysis.     In  this  way  the 


576  LECTur.ES  on  nervous  diseases. 

development  of  strabismus  and  ptosis  is  to  be  explained.  Again,  the 
muscles  of  the  organs  associated  with  speech  and  swallowing  may  be 
paral3'zed. 

The  Mental  Type. — In  connection  with  chronic  alcoholism,  the 
mental  condition  of  the  patient  is  liable  to  be  seriously  impaired.  Illu- 
sions and  hallucinations  are  not  uncommon,  and  the  power  of  intellect 
and  will  are  generally  lessened  in  a  marked  degree. 

Emotional  manifestations,  chiefly'  tliose  of  a  "  sorrowful  type."  are 
very  frequently  observed.  A  large  proportion  of  these  subjects  are 
prone  to  weep  easily  over  imaginary  troubles,  and  to  exhibit  a  disposi- 
tion to  greatly  exaggerate  their  business  cares  and  perplexities.  Those 
who  are  naturally  inclined  to  be  vicious  may  be  rendered  still  more  so 
by  this  form  of  alcoholic  poisoning.  It  has  not  been  my  experience, 
however,  to  encounter  any  exhibitions  of  mental  disturbance  in  this  class 
of  patients  that  would  justl}^  create  alarm.  They  are  far  more  apt  to 
become  exti'emely  irritable,  peeA'ish,  and  lachr^'mose.  They  are  very 
liable  to  take  offense  easily,  and  to  misconstrue  unintentional  acts  of 
their  friends  and  companions  as  personal  slights  and  insults. 

Suicidal  tendencies  may  occasionall}^  be  observed  in  these  patients 
as  the  results  of  melancholia  or  imaginary  fears.  One  of  my  patients, 
Avho  was  a  very  rich  man,  was  constantly  haunted  by  the  fear  of  beggar}'', 
and  was  with  difliculty  restrained  from  acts  of  violence  to  himself. 

The  capabilities  of  the  patient  for  mental  application  or  for  accurate 
reasoning  in  respect  to  the  ordinary  affairs  of  life  is  liable  to  be  seriousl}'" 
impaired.  Their  sense  of  comprehension  is  often  A'ery  much  blunted,  and 
their  judgment  is  often  seriously  in  error.  Hammond  states  that  the 
memor}^  is  the  first  facult}-  which  shows  impairment,  and  that  the  sense 
of  right  and  justice  which  the  patient  may  have  had  in  health  is  often 
weakened  or  destroyed.  This  author  lays  stress  upon  the  fact  that  lying, 
stealing,  and  even  serious  outrages  without  known  provocation,  may  be 
committed  by  these  patients  ;  and  he  regards  the  existence  of  any  mot  ive 
for  such  acts  as  extremely  infrequent  among  this  class  of  sufferers, 

Ilallucinations  and  delusions  in  chronic  alcoholism,  as  in  the  acute 
form,  tend  to  assume  a  peculiarl^^  painful  and  distressing  character. 
These  patients  are  frequently  the  victims  of  fear  of  personal  violence 
either  to  themselves  or  those  to  whom  they  are  attached.  There  are 
exceptional  instances,  however,  where  the  delusions  assume  a  more 
pleasant  character. 

Prognosis. — In  the  acute  form  recovery  usually  occurs,  provided  the 
attacks  have  not  been  frequent.  Convulsions  in  this  form  give  a  grave 
aspect  to  the  case.  A  failure  of  the  digestive  organs  to  assimilate  food 
after  the  symptoms  have  subsided  to  a  greater  or  less  extent  is  also  an 
unfavorable  sign. 


CHKONIC   ALCOHOLISM.  577 

The  chronic  form  may  he  recovered  from  when  the  symptoms  are. 
not  of  a  severe  type,  and  when  the  patient's  appetite  for  liquor  can  be 
ertectually  controlled. 

Treatment. — An  attack  of  delirium  tremens  demands  active  roedica- 
tion  to  induce  sleep,  and  careful  attention  to  the  nourishment  of  the 
patient.  It  is  m}'  custom  to  administer  thirty  grains  of  the  bromide 
of  potassium  and  ten  grains  of  chloral,  combined  with  ten  drops  of  the 
tincture  digitalis,  to  a  patient  sutfering  from  delirium  tremens,  every 
hour  or  two  as  the  circumstances  seem  to  demand,  until  sleep  is  induced. 
The  digitalis  is  added  as  a  preventative  of  heart-failure,  which  sometimes 
occurs  from  chloral-poisoning.  Wlien  sleep  is  not  induced  by  this  pre- 
scription within  five  or  six  hours,  a  hypodermic  injection  of  a  quarter  of 
a  grain  of  morphine  may  be  given  and  repeated  in  two  hours. 

The  monobromide  of  camphor  has  been  recommended  in  doses 
of  four  grains  every  hour  for  several  hours,  I  have  had  no  personal 
experience  in  its  use. 

Sometimes  the  administration  of  capsicum  by  the  stomach  acts 
charmingly  in  inducing  sleep.  A  teaspoonful  of  the  tincture  may  be 
given  at  a  dose. 

During  the  attack,  the  patient  should  be  carefully  watched  by  an 
attendant  in  order  to  guard  against  danger  to  the  patient,  as  they  are 
very  prone  to  jump  from  the  window,  or  do  themselves  some  personal 
violence  in  their  efforts  to  escape  from  the  imaginary  objects  which 
haunt  them.  It  is  well  to  remove  from  the  room  all  articles  of  china 
and  other  utensils  which  might  be  employed  by  the  patient  as  a 
weapon.  One  of  my  patients  committed  suicide  by  breaking  the 
handle  from  a  heavy  earthen  pitcher  and  cutting  his  throat  with  its 
ragged  edge. 

The  patient  should  be  nourished  at  regular  intervals  with  milk, 
beef-tea,  gruels,  and  other  liquid  foods.  During  convalescence,  quinine, 
iron,  and  strychnia  may  be  indicated. 

The  treatment  of  chronic  alcoholtHyn  consists  in  an  entire  cessation 
of  alcoholic  liquors.  If  the  bowels  are  deranged  by  constipation  or 
diarrhoia,  they  should  be  regulated. 

When  insomnia  is  a  prominent  symptom,  the  bromides  alone,  or  a 
combination  similar  to  that  used  in  delirium  tremens,  may  be  employed. 

The  oxide  of  zinc,  in  doses  of  from  one  to  three  grains  three  times  a 
day,  has  been  highly  recommended  in  this  affection.  Hammond  suggests 
the  use  of  bromide  of  zinc  in  doses  of  two  grains  three  or  four  times  a 
day.  This  drug  may  be  given  in  solution  with  water  or  s^-rup.  The 
dose  should  be  gradually  increased  (up  to  four  or  even  six  grains  at  a 
time)  as  rapidl}^  as  the  stomach  will  permit. 

The  infusion  of  digitalis^  in  doses  of  a  tablespoonful  three  times  a 

37 


i)iS  LECTUKES  ON   NERVOUS  DISEASES. 

day,  is  often  indicated  to  increase  tlie  power  of  the  heart  and  indirectly 
to  stimulate  the  action  of  the  kidneys. 

Electrical  applications  to  the  atiected  muscles  ma}'  be  administered 
daily  for  from  five  to  ten  minutes.  The  ftiradaic  or  galvanic  currents  may 
be  emploj'Cd,  and  also  the  static  current  in  the  form  of  spark  or  static 
insulation.  I  have  great  faith  in  static  sparks  as  a  curative  agent  in 
alcoholic  tremor  and  paresis.  When  anaesthesia  exists  the  faradaic 
current  is  best  applied  by  means  of  the  wire  brush. 

Careful  regard  to  the  diet  of  these  patients  should  be  observed.  All 
highly  seasoned  food  should  be  countermanded,  and  large  quantities  of 
milk  should  be  taken  by  the  patient,  I  have  great  faith  in  the  curative 
effects  of  an  exclusive  milk  diet  in  these  cases.  Three  quarts  of  milk  a 
day  are  amply  sufficient  to  nourish  an  adult  without  a  particle  of  solid 
food.  The  addition  of  a  slight  quantity  of  lime-water  or  some  of  the 
admirably  made  preparations  of  pepsin  may  assist  in  its  digestion  in 
those  exceptional  cases  where  milk  is  not  well  tolerated  by  the  stomach. 

MERCUEIAL  POISONING. 
{Hiidrargysim.) 

Mercury  may  be  taken  into  the  system  not  onl}'  by  the  stomach  and 
intestines,  but  also  tlirough  tlie  skin  and  lungs. 

This  drug  is  often  taken  to  excess  in  the  form  of  blue  pill  and  calo- 
mel. Mercury  is  used  extensively  in  some  of  the  manufacturing  arts, 
such  as  the  silvering  of  looking-glasses,  the  making  of  artificial  flowers, 
the  manufacture  of  bronzes,  some  of  the  photographic  processes,  certain 
forms  of  dental  work,  etc.  Some  of  the  cosmetics  for  tlie  removal  of 
facial  eruptions  contain  mercury.  I  have  observed  several  cases  of  mer- 
curial poisoning  from  an  injudicious  use  of  the  vapor  of  mercury  in  a 
bath  given  for  medicinal  purposes.  This  is  particularly  apt  to  occur 
when  calomel  is  employed,  or  when  the  A'apor  is  inhaled  into  the  lungs. 

Symptoms. — In  chronic  mercurial  poisoning,  tremor  is  peculiarl}' 
apt  to  be  developed. 

When  salivation  is  thus  produced,  the  gums  will  appear  very  much 
swollen,  sensitive,  liable  to  bleed  easily,  and  more  or  less  separated  from 
the  teeth.  The  breath  is  extremely  fetid,  and  the  teeth  are  apt  to  become 
loosened  from  their  sockets.  The  patient  complains  of  a  metallic  taste 
in  the  mouth.  In  severe  cases,  the  tongue  becomes  enormouslj^  swollen, 
often  to  such  an  extent  as  to  protrude  from  the  mouth.  The  saliva 
flows  in  a  stream,  so  that  the  patient  has  frequently  to  hang  the  head 
over  a  bowl,  which  catches  it  as  it  escapes  from  the  mouth.  The  coun- 
tenance may  be  pale  or  livid.  Severe  nose-bleed  sometimes  occurs.  The 
physical  strength  is  very  rapidly  lost,  and  marked  mental  debility  may 
be  exhibited. 


BKOMISM.  579 

In  some  cases,  caries  and  necrosis^  espeeiully  of  the  lower  jaw,  with 
ulcerations  of  the  soft  parts,  may  develop. 

Finally,  convulsions  of  the  epileptiform  type  and  paralyses  of 
various  parts  of  the  body  have  been  reported. 

Diagnosis. — The  symptoms  of  this  form  of  poisoning  can  hardly  be 
mistaken  for  those  of  any  other  disease. 

The  tremor,  the  peculiarly  fetid  odor  to  the  breath,  the  characteristic 
appearance  of  the  gums,  the  loosening  of  the  teeth,  the  swelling  of  the 
tongue,  the  enormous  increase  of  saliva,  and  the  bone-complications 
frequently  encountered,  are  met  with  in  no  other  condition. 

It  is  claimed  that  the  diagnosis  may  be  rendered  certain  when  the 
53-mptoms  are  not  full}-  developed,  b^'  the  administration  of  the  iodide 
of  potassium  to  the  patient  in  large  doses  for  two  daj^s,  and  then 
subjecting  a  few  drops  of  the  urine  on  a  bright  copper  plate  to  a  drop  of 
h3'drochloric  acid.  If  mercury  is  present,  a  bright  metallic  spot  will  be 
found  on  the  copper  plate. 

The  history  of  the  patient  will  usually  rcA'eal  the  fact  that  he  has 
been  exposed  to  the  poisonous  influences  of  mercury. 

Treatment. — During  an  attack  of  saliA'ation,  tannic  acid  may  be 
employed  as  a  gargle,  with  very  great  relief  to  the  patient.  The  admin- 
istration of  the  iodide  of  potassium  in  doses  of  from  15  to  30  grains 
three  times  a  day,  aids  in  the  elimination  of  the  poison. 

When  mercurial  tremor  is  the  prominent  symptom  in  the  case,  the 
use  of  the  iodide  of  potassium  is  often  followed  by  a  verj^  rapid  cessation 
of  that  symptom. 

The  administration  of  iron,  quinine,  and  strychnia  in  tonic  doses 

may    prove   valuable   as   adjuncts   in   the   treatment   of   this   form   of 

poisoning.     The  patient  should  be  warned  against  further  exposure  to 

mercur}'. 

BROMISM, 

The  bromides  which  are  chiefly  administered  as  drugs  in  the  treat- 
ment of  most  of  the  functional  nervous  diseases  comprise  those  of 
potassium,  sodium,  calcium,  lithium,  ammonium,  zinc,  and  camphor. 

The  extent  to  which  these  drugs  are  employed  probabl}-  exceeds 
to-day  that  of  any  known  class  in  the  treatment  of  nervous  diseases  ; 
hence,  I  feel  it  my  duty  to  raise  my  voice  here  in  protest  against  the 
view  too  commonly  held  by  practitioners,  that  these  bromide  preparations 
are  harmless,  and  that  they  are  indicated  in  every  functional  nervous 
disturbance  whose  cause  may  be  obscure. 

I  believe  that  more  harm  has  been  done  to  the  human  race  by  the 
bromides  than  good.  In  epilepsy,  for  example,  the  continued  adminis- 
tration of  ver^'  large  doses  of  the  various  bromide  salts  unquestionably 
assists   in  bringing  the   mental   state    of  the   patient  to  a  deplorable 


580  LECTURES   ON    NERVOUS   DISEASES. 

condition,  in  depressing  tlie  digestive  functions,  in  weakening  the  general 
muscular  tone,  and  in  seriously  delaying  (if  it  does  not  sometimes  pre- 
vent) the  recovery  of  the  patient  in  many  instances. 

I  have  known  of  several  epileptics  where  recurring  dislocations  of 
the  shoulder  could,  in  lu}^  opinion,  be  attributed  to  a  relaxed  state  of  the 
muscles,  which  had  been  induced  by  excessive  and  long-continued  admin- 
istration of  the  bromides.  I  have  seen  a  very  large  number  of  patients 
precipitated  into  a  condition  closel}'  bordering  upon  imljecility  from  the 
same  cause. 

Personall}^,  I  have  for  some  years  avoided  the  use  of  bromides  as 
far  as  possible  in  the  treatment  of  functional  nervous  diseases  ;  and  I 
believe  that  by  so  doing  I  have  greatly  added  to  the  comfort  and  health 
of  my  patients.  The  prevention  of  convulsive  nervous  phenomena  by 
the  continued  use  of  a  drug  whose  poisonous  effects  are  well-known  and 
generally  recognized,  cannot  be  considered  in  any  light  as  a  cure.  It  is 
a  question  to  my  mind  if  epileptics,  for  example,  do  not  improve  as  much 
under  a  well-regulated  diet  from  which  nitrogen  is  eliminated  as  far  as 
possible,  and  the  use  of  other  drugs  than  the  bromides  whose  poisonous 
effects  are  far  less  marked  if  not  totally  absent,  than  by  the  use  of 
bromide-salts,  which  tend  in  time  to  render  their  mental  condition,  if  not 
their  physical,  a  deplorable  one  in  many  cases. 

Symptoms. — The  poisonous  effects  of  bromine  may  be  developed  in 
some  adults  and  often  in  children,  from  very  small  quantities  of  the  drug. 

The  evidences  of  its  poisonous  effects  may  be  manifested  in  a 
variety  of  ways.     I  shall  consider  some,  of  these  effects  in  detail. 

Excessive  somnolence  is  an  earh'  symptom.  The  patient  may  sleep 
or  remain  in  a  drowsy  condition  not  only  during  the  night,  but  also 
during  the  da^. 

A  feebleness  in  the  legs  and*  in  the  arms,  may  tend  to  develop. 
This  is  shown  by  a  marked  alteration  in  the  gait  and  a  loss  of  the  grasp- 
ing power  of  the  hand. 

The  liearVs  action  may  he  markedly  weakened ,  and  the  pulse  propor- 
tionately accelerated.  Frequently  the  skin  is  rendered  cold  and  clammy, 
and  the  pupils  may  be  occasionally  widely  dilated  and  I'endered  insensible 
to  the  action  of  strong  light. 

Pustular  eruptions  may  develop  upon  the  skin — chiefly  upon  the 
face,  neck,  and  trunk.  Boils  and  carbuncles  have  been  known  to  follow 
the  abuse  of  the  bromides. 

The  digestive  organs  are  very  often  seriously  distu7-bed.  This  is 
shown  b}'  a  coating,  unnatural  dryness,  and  occasionally  an  excessive 
soreness  of  the  tongue.  The  bowels  are  usually  constipated  nnd  the 
1)reath  has  a  fetid  odor.  The  mucous  membrane  of  the  mouth  and  fauces 
may  become  covered  with  aphthous  patches,  and  show  a  markedly  con- 


TETANUS.  581 

jested  state.  A  similar  condition  is  probably  induced  in  the  mucous 
linin<>:  of  tlie  respiratory  passages;  as  evidenced  by  accelerated  respira- 
tion, cough,  and  the  physical  signs  of  bronchitis. 

The  mucous  lining  of  the  pharynx,  larynx,  and  the  bladder  may  lose 
its  normal  sensibility.  Specialists  on  the  throat  employed  this  agent  often 
for  the  purpose  of  rendering  the  introduction  of  instruments  into  the 
pharynx  and  larynx  possible  without  exciting  nausea  or  efforts  to  vomit. 

In  severe  cases  of  bromism,  walking  often  becomes  impossible;  the 
patient  lies  in  a  deep  stupor;  the  sphincters  are  no  longer  controlled; 
the  heart's  action  is  excessively  weakened ;  lung  complications  are 
developed ;  and  death  may  occur. 

Treatment. — When  bromism  has  developed,  the  administration  of 
the  drug  should  be  immediately  discontinued.  Digitalis  may  be  given 
to  increase  the  power  of  the  heart  and  thus  to  excite  the  action  of  the 
kidneys.  The  patient  should  be  stimulated  judiciously,  and  nourished 
at  regular  intervals.     Tonics  may  be  given  during  convalescence. 

TETANUS. 

(  Trismus — Lock-jaw.) 

This  disease  is  characterized  by  an  exaggerated  excitability  of  the 
motor  and  reflex  functions  of  the  spinal  cord.  It  manifests  itself  b}' 
convulsive  seizures  of  a  tonic  character.  Its  course  is  usually  a  rapid 
one.     Consciousness  remains  intact  throughout  the  disease. 

Etiology. — Tetanus  is  commonly  divided  into  four  varieties,  viz., 
the  traumatic,  rheumatic,  toxic,  and  idiopathic.  To  these  varieties  some 
authors  add  the  hysterical,  inflammatory ,  intermittent,  and  that  of  the 
newly  born  (trismus  neonatorum). 

Lock-jaw,  or  "  trismus,^^  is  considered  by  some  authorities  as  a  dis- 
tinct disease.  With  this  view  I  am  not  in  accord,  since  spasms  of  the 
jaw-muscles  are  nearly  always  combined  with  spasms  of  the  trunk  and 
limbs.     I  regard  typical  trismus  as  but  a  modified  form  of  true  tetanus. 

The  trainnatic  variety  is  the  most  frequently  encountered.  It  seems 
to  occur  in  some  regions  more  than  in  others.  The  atmosphere  of  some 
localities  apparently  renders  any  wound  particularly  dangerous  on  this 
account.  Contused  and  torn  wounds  about  the  hands  and  feet,  especially 
if  they  injure  nerves  or  tendons,  are  peculiar!}^  liable  to  be  followed  by 
tetanus.  It  is  thought  by  the  laity  that  a  wound  inflicted  by  a  rusty 
piece  of  iron  is  particularly  apt  to  cause  this  condition. 

Tetanus  ma^-  follow  immediately  after  a  wound,  or  it  may  develop 
after  a  lapse  of  several  days  or  weeks. 

Among  the  predisposing  causes  to  tetanus  may  be  mentioned  certain 
psychical  influences,  irritation  of  the  wound,  epidemic  influences,  atmos- 
pheric conditions,  concussion  of  the  head  or  spine,  p^a^mic  poisoning,  etc. 


582 


LECTURES   ON   NERVOUS  DISEASES. 


The  exciting  woiiiid  miiy  be  extremely  insignificant  in  some  cases. 
Tetanus  lias  been  known  to  Ibllovv  tUe  sting  of  a  bee,  the  pulHng  of  a 
tooth,  the  piercing  of  the  ear,  ulcerations,  etc. 

Among  other  forms  of  injuries  received  of  a  more  serious  character, 
which  have  resulted  in  tetanus,  may  be  mentioned  the  wounds  of  the 
surgeon's  knife,  lacerations  of  the  cervix  uteri,  the  exposure  of  an 
abraded  mucous  membrane  (as  in  the  puerperal  state),  and  accidental 
traumatisms  of  various  kinds. 

A  variety  of  tetanus  is  not  uncommonly  observed  between  the  fifth 
and  twelfth  days  of  life,  which  is  known  as  "  trismus  neonatorum.''^  It 
may  be  attributed  in  many  cases  to  disease  of  the  umbilicus,  faecal  stasis, 
and  mechanical  irritation  of  the  medulla  oblongata  from  strong  extension 
of  the  head  during  delivery. 


Fig.  127. — A  Makkeu  Paroxysm  of  Tetanus.     (After  a  drawing  by  Sir  Chas.  Bell  ) 


The  rheumatic  variety  of  tetanus  is  a  rare  form  of  disease.  Many 
authors  of  to-day  express  a  doubt  as  to  whether  genuine  tetanus  is  ever 
dependent  upon  exposure  to  cold  or  dampness,  or  an  excess  of  lactic 
acid  in  the  blood. 

The  toxic  variety  of  tetanus  may  occur  in  certain  forms  of  poisoning 
by  drugs,  chiefly  from  an  overdose  of  strychnine  or  picrotoxine.  It  is 
stated  by  some  authors  that  clonic  muscular  spasms  are  more  often  noted 
than  the  tonic  in  this  variety  of  tetanus. 

The  idiojMthic  variety  of  tetanus  comprises  all  cases  in  which  no 
exciting  cause  can  be  discovered.  In  many  such  cases  the  presence  of 
an  epidemic,  due  probably  to  some  atmospheric  influences,  exists. 

Symptoms. — After  a  wound,  the  onset  of  tetanus  is  usuall}^  preceded 
b}^  more  or  less  pain  in  the  region  of  the  wound,  or  an  unnatural  appear- 
ance of  the  injured  part.  These  pains  frequently  shoot  along  the  course 
of  some  adjacent  nerve.     Local  symptoms  are  often  accompanied  by  a 


TETANUS.  583 

peculiar  restless,  excited,  or  anxious  condition  of  the  patient.     Insomnia 
may  be  a  marked  symptom. 

As  the  onset  of  the  disease  approaches,  movements  of  the  jaw  are 
associated  with  more  or  less  pain  and  stitl'ness,  as  are  frequently  also 
movements  of  the  neck  and  attempts  at  swallowing.  The  first  signs  of 
muscular  spasm  generally  appear  in  the  face  and  in  the  back  of  the  neck. 
Later,  a  similar  condition  develops  in  the  muscles  of  mastication,  in  the 
})har3'nx,  and  in  the  muscles  of  the  back  and  limbs.  In  many  instances, 
the  extremities  are  but  slightly  atfected. 

The  facial  expression  of  tetanus  is  characterized  by  a  peculiar 
wrinkling  of  the  forehead,  an  expansion  and  elevation  of  the  nostrils, 
and  an  attitude  of  the  mouth  which  exposes  the  teeth,  giving  to  it  the 
expression  termed  the  "  risus  sardonicus  "  because  it  resembles  that  of 
laughter.  Respecting  this  peculiar  condition  of  countenance,  Eichhorst 
very  aptly  says :  "•  The  features  express  the  most  antagonistic  feelings. 
While  the  upper  half  of  the  face  has  a  cheerful  though  tired  expression 
(due  to  diminution  in  the  size  of  the  palpebral  fissure),  the  lower  part  is 
sad,  and  the  mouth  has  the  expression  of  one  who  is  sobbing.  On 
account  of  the  uncovering  of  the  teeth,  the  expression  has  been  com- 
pared to  that  of  laughing." 

The  abilit}'  to  open  the  mouth  is  partially  or  completely  lost  by  a 
tonic  state  of  the  masseter  muscles.  This  interferes  seriously  with  the 
ability  of  the  patient  to  take  food.  Infants,  when  attacked  by  tetanus 
are  unable  to  retain  the  nipple  between  the  jaws.  Any  attempt  to  open 
the  mouth  is  so  strongly  resisted  that  a  danger  of  fracture  or  dislocation 
of  the  lower  jaw  might  be  created  before  the  spasm  could  be  overcome. 
The  nutrition  of  the  patient  is,  furthermore,  embarrassed  hj  a  similar 
state  of  the  muscles  of  the  pharyx,  in  some  cases.  The  tortures  of 
hunger  and  thirst  may  therefore  constitute  an  important  part  of  the 
sufterings  of  the  patient. 

During  the  paroxysm  the  head  is  drawn  forcibly  backward,  and 
the  muscles  of  the  back  distort  the  trunk  so  that  the  patient  may  rest 
upon  his  shoulders  and  hips.  In  occasional  instances,  the  trunk  may 
be  bent  toward  one  side  (pleurosthotonus)  ;  or  the  body  may  be  drawn 
forward  toward  the  thigh  (emprosthotonus).  Cases  have  been  reported 
where  the  trunk-muscles  have  rendered  the  spinal  column  rigid  without 
distortion. 

The  respiratory  movements  are  seriously  embarrassed  when  the 
diaphragm  and  the  intercostals  are  affected.  Under  such  circumstances 
extreme  cyanosis  may  develop,  and  death  may  occur  from  a  lack  of 
ability  on  the  part  of  the  patient  to  breathe. 

The  muscles  of  the  limbs  may  participate,  to  a  greater  or  less  extent, 
in  the  tonic  rigidity  so   commonly  observed  in  the  trunk  and  neck. 


584  LECTURES   ON   NERVOUS   DISEASES. 

Flexion  of  the  ui)i)er  limbs  and  extension  of  the  lower  are  generally 
observed.  The  c<)i\tracted  museles  stand  out  with  great  prominence 
beneath  the  skin,  and,  in  severe  eases,  the  patient  maybe  raised  from  the 
bed  so  that  he  rests  upon  his  head  and  heels. 

In  very  exceptional  instances  the  third  cranial  nerve,  in  addition  to 
the  seventh  and  ninth,  may  be  affected  and  cause  a  strabismus.  Eye- 
symptoms  in  tetanus  are  justly  regarded  as  of  evil  import. 

The  frequency  and  duration  of  tetanic  spasms  vary.  During  sleep, 
they  generally  tend  to  subside  or  entirely  disappear.  In  some  cases, 
distinct  paroxysms  are  observed  ;  beginning,  as  a  rule,  with  clonic  con- 
tractions, which  gradually  tend  to  assume  the  tonic  type.  In  other 
cases,  the  tonic  contraction  of  muscles  is  persistent.  Such  a  condition 
ma^'  continue  for  days  without  intermission. 

Tlie  reflex  excitability  of  the  spinal  cord  is  very  markedly  exag- 
gerated in  some  cases.  The  slightest  noise  or  disturbance  of  the  patient 
in  any  way  may  excite  a  paroxysm. 

The  force  of  the  tonic  contractions  of  muscles  has  been  known  to 
break  off  the  teeth,  and  to  fracture  and  dislocate  the  long  bones.  During 
a  paroxysm,  the  development  of  fibrillary  twitchings  in  the  rigid 
muscles  may  occasionally  be  observed. 

The  onset  of  a  paroxysm  is  looked  forward  to  with  great  terror  bA' 
the  patient  on  account  of  the  extreme  pain  which  is  generally  experi- 
enced while  the  muscles  are  thrown  into  rigidity.  In  severe  cases,  the 
patient  is  unable  to  obtain  sleep  or  to  quench  his  thirst  or  hunger. 
Occasionally,  delirium  sets  in  late  in  the  disease ;  but,  as  a  rule,  the  mind 
of  the  patient  is  perfectly  clear.  Profuse  sweating  is  apt  to  occur  during 
the  paroxysms.  The  sensibility  of  the  skin  is  unaffected,  as  a  rule,  and 
little,  if  any,  febrile  excitement  is  usually  observed. 

Diagnosis. — The  only  disease  which  could  be  confounded  with 
tetanus  is  spinal  meningitis.  The  character  of  the  spasms,  the  stilfness 
or  complete  fixation  of  the  jaws,  the  facial  expression  observed  in 
tetanus,  and  the  difficulty  in  swallowing  produced  by  spasms  in  the 
muscles  of  the  pharynx  are  sufficient  to  distinguish  tetanus  from  an 
inflammatory  affection  of  the  spinal  meninges. 

Prognosis. — The  duration  of  tetanus,  as  well  as  the  character  of  its 
symptoms,  vai-y  in  individual  cases.  A  case  is  reported  where  death 
occurred  in  a  negro  fifteen  minutes  after  the  accident ;  while,  on  the 
other  hand,  the  duration  ma}'  extend  over  a  period  of  weeks  or  months. 
Paralysis  and  paresis  have  been  known  to  occur  as  sequelae  of  tetanus. 

The  mortality  in  infants  is  enormoush'  large.  In  adults,  the  severity 
of  the  symi)toms  and  the  exciting  cause  of  the  attack  materially  modify 
the  prognosis.  In  a  large  percentage  of  cases  it  is  unfavorable.  A  long 
duration  of  the  disease  without  rise  in  temperature  or  marked  insomnia 


TETANUS.  585 

indicates  a  favorable  termination.  The  idiopathic  variety  is  more  often 
recovered  from  tlian  the  traumatic.  The  prognosis  is  also  more  favorable, 
in  case  the  attack  be  of  the  traumatic  type,  when  a  long  interval  elapses 
between  the  exciting  injury  and  the  development  of  tetanic  phenomena. 

Treatment  — The  indications  for  treatment  are  modified  b}'  the 
exciting  cause  and  the  symptoms.  When  an  open  wound  exists,  perfect 
cleanliness  and  antiseptic  dressings  should  be  employed.  The  patient 
should  be  placed  in  a  darkened  and  quiet  room  ;  and  ever}"  precaution 
should  be  taken  to  avoid  a  recurrence  of  tlie  paroxysms. 

The  patient  may  often  be  nourished  by  means  of  a  tube  passed 
behind  the  last  molar  tooth  and  through  the  pharynx  into  the  stomach. 
When  this  is  impossible,  the  patient  may  be  put  under  the  influence  of 
ether  or  chloroform  and  a  tube  introduced  between  the  teeth  ;  or,  when 
that  is  impossible,  through  the  nostril  into  the  stomach. 

Among  the  drugs  which  have  been  highly  recommended,  the  follow- 
ing may  be  mentioned  :  Calabar  bean,  cannabis  indica,  conium,  anaes- 
thetics, chloral  and  bromide  of  potassium  in  large  doses,  gelsemium  in 
doses  of  from  ten  to  forty  drops  every  two  hours,  paraldehyd  in  doses 
of  from  thirty  grains  to  two  drachms  during  the  twenty-four  hours, 
belladonna,  and  aconite. 

Ice-bags  and  counter-irritants  ma}'  be  applied  to  the  spine.  Ether 
spray  and  leeches  have  also  been  employed  over  this  region. 

Certain  surgical  procedures  have  been  recommended.  Among  these, 
stretching  of  the  nerve  leading  to  the  wound  may  be  mentioned  as  having 
given  satisfactory  results  in  a  few  cases.  Accumulations  of  pus  may 
demand  an  incision  in  tlie  region  of  the  wound,  and  care  should  be  taken 
to  free  the  wound  from  the  presence  of  any  foreign  substances  which 
may  have  entered  at  the  time  of  the  accident. 

Hammond  has  carefully  analyzed  the  results  of  treatment  in 
reported  cases  which  were  obtained  by  most  of  the  drugs  enumerated  ; 
and  by  surgical  procedures  in  typical  cases  of  tetanus.  The  Conclusions 
of  this  author  go  to  show  that  some  cases  apparently  recover  rather  in 
spite  of  drugs  than  by  their  direct  aid.  Perhaps  it  may  be  said  that 
large  doses  of  chloral,  combined  with  lai-ge  doses  of  the  bromide  of 
potassium,  give  as  much  relief  to  the  patient  as  any  known  treatment. 
The  api)lication  of  ice-bags  to  the  spine,  combined  with  the  internal 
administration  of  half  a  grain  of  the  extract  of  cannabis  indica  every 
two  hours,  may  be  attended  with  good  results. 

I  have  been  awaiting  for  some  time  an  opportunity  to  test  the  effects 
of  strong  static  spar'ks  upon  a  patient  in  a  paroxysm  of  tetanus,  on 
account  of  the  remarkable  effect  which  such  an  electrical  application 
seems  to  exert  upon  muscular  contracture.  Thus  far  I  have  been 
unsuccessful  in  obtaining  an  opportunity  of  this  kind. 


586  LECTURES   ON   NERVOUS   DISEASES. 


TREMOR 

AND 

PARALYSIS   AGITANS. 

Intermittent  clonic  spasms  of  the  muscles,  of  a  persistent  type,  are 
not  infrequently  observed  in  connection  with  any  condition  which 
increases  the  susceptibility  of  the  patient  to  central  or  peripheral 
irritation,  or  renders  the  action  of  the  nerve-centres  more  or  less 
imperfect. 

Etiology. — In  the  human  race,  the  presence  of  persistent  tremor 
usually  indicates  a  condition  of  irritation  in  the  nerve-centres. 

This  condition  may  be  dependent  upon  a  morbid  lesion;  such  as 
inflammatory  processes,  tumors,  sclerosis,  changes  in  the  vessels,  etc. 
It  may  also  be  apparently  due  to  some  excessive  mental  strain  or  excite- 
ment in  subjects  predisposed  to  nervous  disturbances;  hence,  it  has  been 
known  to  follow  sorrow,  fright,  prolonged  anxiet}',  protracted  mental 
application,  religious  excitement,  etc.  Again,  degenerations  of  the  cord 
or  brain,  which  may  or  may  not  follow  or  accompany  an  attack  of  paresis 
or  paralj^sis,  may  cause  persistent  clonic  spasms  in  the  limbs  or  trunk. 
Finally,  nervous  and  easily -excited  individuals,  who  inherit  the  so-called 
"neuropathic  predisposition,'''  may  develop  tremor  in  some  of  its  forms 
simply  as  the  result  of  peripheral  irritation.  In  this  class  of  patients, 
my  experience  leads  me  to  believe  that  eye-strain  exists  more  frequently 
as  an  exciting  cause  than  is  generally  suspected.  (See  my  remarks 
respecting  chorea  and  other  convulsive  diseases.) 

It  has  been  noted,  in  connection  with  some  of  the  toxic  neuroses, 
that  tremor  is  often  induced  by  the  introduction  of  poisons  into  the 
general  sj'stem.  Under  this  class  of  causes,  chronic  alcoholism,  the 
opium  habit,  excessive  use  of  tobacco,  and  mercury  or  lead-poisoning 
may  be  prominentl3'  mentioned.  In  such  cases,  the  morbid  evidences  of 
a  multiple  neuritis  can  often  be  detected. 

Finall}' ,  the  weakness  of  old  age  is  often  manifested  b}'  the  develop- 
ment of  persistent  tremor. 

PARALYSIS   AGITANS. 
(Pai'Linson's  Disease — Shaking  Palsy.) 

This  form  of  tremor  was  first  carefully  observed  and  described  by 
Parkinson  in  1817.  It  is  characterized  by  a  tendency  to  steadity  pro- 
gress both  in  extent  and  severity,  and  to  be  accompanied  by  evidences 
of  enfeebled  motor  i)ower  or  general  paralysis. 

Morbid  Anatomy. — The  anatomical  changes  which  occur  in  this 
disease  are  unknown.  By  some  observers,  morbid  changes  (pigmenta- 
tion, hypertrophy,  etc.)  have  been  detected  in  the  ganglionic  cells  of  the 


PARALYSIS   AGITANS.  587 

brain  and  spinal  cord,  chiefly  in  the  pons,  medulla,  and  Amnion's  horn. 
Our  knowledge  of  these  changes  is,  however,  so  imperfect  that  we  are 
as  yet  forced  to  consider  this  disease  as  a  i^urely  functional  one. 

Etiology. — Among  the  causes  of  this  attection  which  have  been  men- \ 
tioned  by  authors  of  note,  the  following  conditions  seem  to  predispose  ; 
to  it :    Exposure  to  cold,  injuries,  excessive  fright,  prolonged   mental  / 
excitement,   excessive   venery,    certain    infectious    diseases,    heredity/ 
excesses  in  alcohol,  gout,  etc. 

In  many  of  these  subjects,  an  inquiry  into  the  health  of  the  patient's 
blood-relations  will  often  show  that  corea,  epilepsy,  hysteria,  insanity, 
neuralgia,  or  phthisis  has  existed  in  some  branches  of  the  family.  Per- 
sonally, I  regard  the  question  of  heredity  as  one  which  should  always 
be  thoroughly  investigated.  It  tends  to  shed  much  light  upon  the 
possible  factors  which  aid  in  creating  diseased  conditions. 

Among  the  traumatic  cases,  injuries  to  nerve-trunks  are  more 
frequently  followed  b3'  this  condition  than  other  forms  of  accident. 
This  disease  has,  how^ever,  been  known  to  follow  the  opening  of  a  car- 
buncle, a  severe  burn,  and  other  peripheral  injuries. 

Symptoms. — Shaking  palsy  is  very  rare  before  the  age  of  twenty 
years.  It  usually  occurs  in  advanced  age,  chiefly  between  forty  and 
sixt}^  j^ears  of  age.     It  seems  to  aflect  both  sexes  equally. 

The  onset  of  this  disease  is  usually  so  gradual  (except  in  cases 
where  it  originated  after  a  severe  fright)  that  the  patient  cannot 
accurately  locate  when  the  first  SA-mptoms  were  observed. 

Prior  to  the  development  of  the  onset,  the  patient  may  have  suffered 
from  marked  insomnia,  unnatural  irritability,  temporary  weakness  of 
the  limbs,  vertigo,  neuralgic  pains,  and  parsesthesiae. 

The  disease  first  manifests  itself  by  slight  trembling  in  the  muscles 
of  the  fingers  and  hands ;  later  in  the  muscles  of  the  arms ;  and  still 
later  in  the  legs.  It  is  claimed  that  the  right  arm  and  the  corresponding 
leg  are  markedly  affected  before  those  of  the  left  side.  While  this  may 
be  generally'  true,  it  is  not  in  my  experience  an  universal  rule.  Some- 
times the  muscles  in  the  head  and  face  may  be  attacked  with  tremor ;  in 
which  case  the  tongue  is  also  liable  to  be  involved. 

The  trembling  of  the  muscles  is  present  during  repose;  and  does  not 
seem  to  be  afiected  by  voluntary  movements.  They  are  intensified, 
however,  by  an}-  form  of  mental  excitement.  Although  at  first  the 
patient  may  partially  control  them  by  an  act  of  will,  the  tremulous 
moA'Cments  soon  become  uncontrollable,  and  persist  even  during  sleep. 
In  the  latter  stages  of  the  disease,  the  tremors  tend  to  become  exces- 
sively violent.  Cases  have  been  reported  where  the  floor  as  well  as  the 
bed  have  been  set  in  vibration  hy  tlie  shakings  of  the  patient.  It  is 
needless,  perhaps,  to  state  that  the  ability  to  perform  delicate  movements 


588  LECTURES   ON   NERVOUS   DISEASES. 

of  the  fingers  is  rapidly  lost;  and  that  the  patient  sooner  or  later  may 
become  unahle  even  to  dress  or  feed  himself. 

The  development  of  jmresifi  and  a  ri(jUlit]i  of  certain  muscles 
generally  accompany  or  follow  the  onset  of  tremor.  In  exceptional 
cases,  paresis  may  precede  the  development  of  tremor. 

An  ab)iormal  attitude  of  the  fingers  is  very  frequently  observed  in 
connection  with  this  disease.  Sometimes  the  fingers  assume  the  attitude 
commonly  emploj'ed  in  holding  the  pen  ;  again,  the  constant  movement 
of  the  thumb  against  the  extended  fingers  gives  to  the  patient  the  appear- 
ance of  rolling  a  ball  in  each  hand  between  the  thumb  and  forefinger; 
finalh',  the  fingers  may  assume  an  attitude  chtn-acterized  by  flexion  of  the 
first  phalanges,  and  over-extension  of  the  second  phalanges,  and  a  flexion 
of  the  third  phalanges.  The  latter  deformity  very  closel}'  resembles  that 
observed  in  connection  with  arthritis  deformans. 

As  a  rule,  the  upper  extremities  are  flexed  also  at  the  elbow,  and  the 
elbow  is  carried  away  from  the  chest.  The  admirable  drawing  made  by 
Charcot  (Fig.  128)  illustrates  this  point. 

The  gait  of  these  patients  is  very  peculiar.  It  has  been  described  on 
a  preceding  page.  As  they  trot  along,  the  knees  are  apt  to  rub  against 
each  other  and  the  feet  to  become  crossed.  In  some  reported  cases  the 
friction  made  by  the  rubbing  of  the  knees  has  given  rise  to  eruptions, 
ulcerations,  and  even  gangrene.  Deformities  of  the  toes  and  pseudo- 
talipes  may  be  detected  in  these  patients.  The  head  is  thrown  exces- 
sively forward,  causing  a  prominence  of  the  seventh  cervical  spine  ;  and 
the  body  is  also  inclined  ver}'  markedly  forward.  A  prominent  author 
speaks  of  this  attitude  as  one  which  indicates  to  the  observer  a  danger 
to  the  patient  of  tumbling  head  over  heels.  When  these  patients 
attempt  to  walk,  if  it  can  be  called  walking  and  not  running,  they 
experience  great  ditficulty  in  suddenly  stopping  or  in  turning  around 
suddenly  to  either  side  (propulsion).  I  have  known  them  to  catch  hold 
of  objects  in  order  to  stop  when  called  upon  to  do  so.  Occasional!}', 
when  a  patient  is  requested  to  walk  backward,  he  continues  to  do  so 
more  and  more  rapidly,  until  he  falls  or  is  stopped  b}'  an  attendant. 
This  condition  is  known  as  that  of  "  retropuhion.'''' 

There  are  no  evidences  of  atrophy  or  trophic  changes  in  the  muscles 
of  the  limbs,  even  in  the  advanced  stages  of  the  disease.  The  sensory 
functions  are  seldom  aflected,  nor  is  the  electrical  irritability  of  the 
muscles  materially  altered.  In  some  cases  an  increase  of  the  deep 
reflexes  has  been  observed. 

A  j)eculiarity  of  facial  expression  is  commonly  observed  in  victims 
of  paralysis  agitans.  It  is  described  as  comparable  to  a  mask,  because 
there  is  so  little  play  of  the  features.  Very  often  the  mouth  is  kept 
wide  open  and  the  saliva  drools  constantly  trom  the  lips.     Articulation 


PAEALYSIS   AGITANS. 


589 


and  deglutition  may  be  embarrassed.  The  voice  is  generally  high  pitched 
and  tremulous.  The  speech  is  liable  to  be  slow  and  monotonous.  Dis- 
turbances of  vision  are  observed  in  many  of  these  patients,  which  are 
exhibited  by  a  ditliculty  in  following  the  lines  on  a  printed  page. 

The  bladder  and  rectum  are  not  usually  impaired.  In  many  cases, 
constipation  exists. 

Diagnosis. — The  tremor  of  this  disease  differs  from  that  of  multijyle 
sclerosis  in  the  fact  that  it  is  not  excited  by  voluntary  movements;  that 


Fig.  12S. — Paralysis  Agitans,  ok  Shaking  Palsy.     (Charcot.) 

it  is  not  accompanied  by  symptoms  of  oscillation  of  the  CA-eball ;  that 
sensor}'  disturbances  are  wanting;  and  that  it  begins  usually  in  the 
upper  limbs.  The  characteristic  gait  is  also  a  prominent  feature  in 
paralj'sis  agitans. 

From  chorea,  it  can  be  told  b}-  the  marked  regularity  of  the  spas- 
modic movements ;  the  persistence  of  the  tremor,  even  during  sleep ; 
the  violence  of  the  shaking;  and  the  fact  that  voluntary  movements  do 
not  increase  the  tremulous  condition  of  the  limbs. 


590  LECTURES   ON  NERVOUS  DISEASES. 

From  the  tremor  of  alcohol,  mercury  and  lead,  the  history  of  the 
patient  would  render  tlie  diagnosis  eas^^  and  the  characteristic  gait 
would  confirm  it. 

Prognosis. — No  immediate  danger  to  life  is  created  l»y  this  disease. 
From  the  period  of  its  onset,  many  years  may  elapse  before  death  occurs 
from  exhaustion.  In  some  cases  the  tremor  may  exhibit  intermissions; 
but,  as  a  rule,  the  disease  tends  to  steadily  advance.  AVhenever  the  tremor 
has  not  become  general,  or  when  the  si)asmodic  movements  are  compara- 
tively slight,  recover}'  has  been  known  to  occur  in  exceptional  cases. 

Treatment. — The  preponderance  of  medical  testimony  goes  to  show 
that  this  disease  is  seldom  permanently  benefited  by  treatment.  Ham- 
mond states,  however,  that  he  has  succeeded  in  curing  eight  out  of 
twenty-five  cases,  and  partially  curing  five  others.  Such  a  remarkable 
result  might  lead  to  the  suspicion  that  all  of  these  cases  were  not  of  a 
typical  character.  The  treatment  which  this  author  adopted  comprised 
the  employment  of  the  primary  current  to  the  spinal  cord,  sympathetic 
nerve,  and  the  affected  muscles,  together  with  the  internal  administration 
of  strychnia  and  phos[)horus.  Four  out  of  the  eight  cases,  Avhich  were 
entirely  cured  by  this  treatment  according  to  the  observations  of  the 
author  cited,  recovered  within  two  months. 

The  first  point  in  the  treatment  of  all  cases  is  to  remove  the  exciting 
cause,  if  possible,  provided  it  can  be  ascertained.  The  value  of  the  con- 
stant current  in  this  disease  is  not  regarded  by  all  autliors  as  highly  as 
by  Hammond.  Static  electricity  has  yielded  satisfactory  results  in  a 
few  reported  cases. 

Internal  administration  of  Fowler's  solution  of  arsenic  yielded 
favorable  results  in  the  experience  of  Eidenberg, 

Hyosc3'amine,  in  doses  of  one-twentieth  of  a  grain  three  times  a  day, 
is  stated  to  have  produced  a  very  marked  improvement  in  some  cases 
reported  by  Oulmont.  The  phosphide  of  zinc,  in  doses  of  one-twelfth 
of  a  grain,  prepared  in  pill  form  and  administered  after  eating,  has  also 
been  highly  recommended. 

As  a  rule  it  is  safe  to  consider  most  cases  of  this  disease,  that 
have  become  well  established,  as  practically  incurable.  The  tremulous 
condition  may  be  improved  by  the  various  remedies  suggested  in  many 
cases;  but,  after  the  cessation  of  treatment,  the  patient  is  apt  to  relapse 
to  his  former  condition. 

Due  regard  should  be  paid  to  the  avoidance  of  all  mental  excitement 
and  excessive  fatigue  of  the  muscles.  The  diet  of  the  patient  should  be 
as  nutritious  as  the  digestive  powers  of  tlie  patient  will  allow  of. 

The  persistent  insomnia  which  these  patients  nre  apt  to  suffer  from 
may  be  controlled  by  the  use  of  a  combination  of  chloral  and  the  bromide 
of  potassium. 


POSTEKO-LATERAL  SPINAL   SCLEEOSIS. 


591 


POSTERO-LATERAL     SPINAL     SCLEROSIS     (GENERIC     ORIGIN). 
(^Friedreich's  Disease — Hereditary  Ataxia — Generic  Ataxia.) 

The  term  that  I  have  selected  by  which  to  designate  this  peculiar 
form  of  ataxia  that  shows  a  marked  tendency  to  affect  family  aroups  has 
been  lately  suggested  and  strongly  advocated 
by  Dr.  W.  Everett  Smith,  in  an  admirable  essay 
on  its  nomenclature.* 

Friedreich  was  the  first,  in  1861,  to  de- 
scribe certain  cases  which  he  had  encountered  as 
those  of  a  type  of  ataxia  which  seemed  to  select 
its  victims  from  lines  of  direct  consanguinity. 
He  believed  that  they  presented  special  points  of 
distinction  from  the  clinical  history  of  ordinary 
locomotor  ataxia.  Since  his  first  description  of 
these  cases,  others  have  published  a  sutlicient 
number  of  similar  cases,  accompanied  by  the 
results  of  an  autopsy,  to  warrant  our  acceptance 
of  this  condition  as  a  distinct  disease. 

Among  those  who  have  contributed  to  the 
literature  of  the  subject  may  be  mentioned 
Friedreich,  Carre,  Topinard,  Immermann,  Riiti- 
meyer.  Carpenter,  Kellogg,  Power,  Hammond, 
and  Smith.  Respecting  some  of  the  cases 
reported,  however,  there  is  apparently  ground 
for  doubt  as  to  whether  they  are  to  be  regarded 
as  typical  representatives  of  generic  ataxia. 

This  form  of  disease  was  observed  by  Fried- 
reich to  affect  nine  persons  in  three  families ; 
Carre,  of  Paris,  reported  seven  cases  in  one 
fomily  ;  eleven  cases  in  two  families  have  been 
described  by  Immermann  and  Riitimever  (as 
quoted  by  Eichhorst) ;  and  six  in  one  family 
have  been  obserA'ed  by  Dr.  W.  E.  Smith.  I 
have  in  my  possession  some  beautiful  sections 
of  the  spinal  cord  taken  from  a  patient  who  w\as 
so  affected  (in  common  with  several  members  of  his  family)  by  Dr.  W. 
Everett  Smith  (late  of  Framingham,  Mass.,  but  now  of  Boston),  and 
kindly  presented  to  me  by  him. 

Morbid  Anatomy. — In   this   disease,  a   degeneration  (more    or  less 
systematic)  not  only  of  the  posterior  columns  of  the  spinal  cord  and 
*  BoUon  Med,  and  Surg.  Jour.,  March  1, 1SS8. 


Fig.  129. — Mokeid  Appearances 
P];esented  in  Hereuitakv 
Ataxia.     (After  Friedreich.) 


592 


LECTURES   ON   NERVOUS   DISEASES. 


the  posterior  nerve-roots,  but  also  of  the  lateral  and  anterior  columns, 
has  been  observed.  Our  knowledge,  however,  rests  upon  only  eleven 
autopsies.  In  tlie  spinal  sections  Avliich  I  possess,  the  crossed 
pyramidal  and  the  direct  p^^ramidal  fibres  of  both  sides  are  somewhat 
affected ;  although  not  to  so  great  an  extent  as  the  columns  of  GoU 
and  Burdach.  Unlilce  in  true  locomotor  ataxia,  females  seem  to  be 
somewhat    more   frequently  affected    than    males.     Although   it   seems 


Fig.  130.— Photl 


Case.     (Reported  by  W.  E.  Smith.) 


to  be  a  systematic  disease  of  both  the  motor  and  sensory  columns  of 
the  spinal  cord,  the  question  is  still  unsettled  regarding  the  projier 
classification  of  this  affection. 

Symptoms. — These  may  begin  during  childhood,  usually  between 
the  fourth  and  seventh  years,  or  at  the  period  of  puberty.  The  lan- 
cinating pains  (which  are  typical  of  true  ataxia)  may  be  wanting ;  or,  in 
some  cases,  they  may  develop  late  in  the  disease.  From  the  very  onset, 
marked  incoordination  of  movement  or  a  sense  of  weakness  is  developed 


POSTEKO-LATERAL   SPINAL   SCLEROSIS. 


593 


in  both  the  upper  and  lower  extremities.  In  some  cases  reported,  the 
ataxic  symptoms  have  been  confined  to  the  upper  limbs.  The  disturb- 
ance of  coordination  is  very  rapidly  developed.  It  may  affect  the 
movements  of  the  head,  the  muscles  of  speech,  and  possibly  those  of  the 
eyeball.  Changes  in  the  pupil  and  defects  of  vision  are  not  commonly 
observed, — a  fact  which  is  a  marked  contrast  to  the  course  commonly 
observed  in  tabes  dorsalis. 


Fig.  131. — Photograph  op  Case.     (Reported  by  W.  E.  Smith.) 


According  to  most  observers,  the  tendon  reflexes  are  usually 
abolished.  The  sensory  functions  are  less  disturbed  than  in  ataxia  of 
adults  ;  although  tactile  anaesthesia  is  generally  developed.  The  muscular 
sense  is  usually  retained  to  a  greater  or  less  extent.  The  plantar  reflex 
may  often  be  retained,  in  spite  of  the  complete  abolition  of  the  knee-jerk. 

Some  time  after  the  symptoms  of  incoordination  appear,  paralysis 
and  contracture  tend  to  develop  in  some  cases,  these  S3'mptoms  are 
usually  more  marked  in  the  lower  limbs  than  in  the  upper.    The  patients 

38 


594 


LECTURES   ON   NERVOUS   DISEASES. 


cannot  walk,  as  a  rule ;  and  free  movements  of  the  hands  or  arms  may 
become  impossible. 

Bed-sores  do  not  occur  in  this  disease.  The  sphincters  are  not 
affected.  The  mental  faculties  seldom  exhibit  any  marked  impairment. 
The  speech,  however,  tends  to  become  of  a  drawling  kind,  and  often 
more  or  less  unintelligible. 

Yaso-motor  disturbances  may  be  observed  ;  chiefly  in  the  form  of 
polyuria,  salivation,  and  excessive  sweating. 

The  two  foregoing  figures  (Figs.  130  and  131,  taken  from  photo- 
graphs made  by  Dr.  Smith),  together  with  the  two  sections  of  the 
cord  of  one  of  these  patients  (Figs.  132  and  133),  which  have  been 
very  accurately  drawn  by  Dr.  H.  P.  Quincy,  present  some  very 
interesting  points  in  relation  to  this  rare  affection. 

The  involvement  of 
the  posterior  spinal  nerve- 
7'oots  was  very  marked  in 
this  case.  The  anterior 
nerve-roots  were  found  to 
be  perfectly  health}'.  The 
clubbed  feet  shown  in  the 
photographs  of  two  mem- 
bers of  this  family  con- 
stituted a  very  marked 
deformity. 

In  Dr.  Smith's  six 
cases,  a  sense  of  weakness 
and  uncertainty  of  move- 
ment  of  the  limbs  pre- 
ceded by  the  development 
of  ataxia  and  girdle- 
pains;  and  likewise  abnormal  sensory  j^henomena  in  five  of  the  subjects. 
Incoordination  of  movement  was  an  early  symptom. 

In  two  cases  "  wrist-drop"  developed.  In  the  two  fatal  cases  reported, 
death  was  preceded  by  symptoms  of  spinal  meningitis  and  myelitis. 

The  movements  of  the  head  were  attended  with  "irregular  oscilla- 
tions," which  were  aggravated  b}'  voluntary  attempts  at  movement  of 
any  part  of  the  body. 

The  limbs  became  greatly  distorted  by  progressive  atroph}^  and  con- 
tractures. Attacks  of  extreme  dyspnoea  and  impending  collapse  were 
frequently  noted. 

In  the  case  sliown  in  the  photographs,  epileptic  attacks  had  occurred 
frequently  for  fifteen  years  prior  to  the  published  notes  upon  her  con- 
dition.    She  had  developed  right  lateral  curvature  with  kyphosis ;  also  a 


>^— PR 


Fig.  132. — Section  op  Dorsal  Region.  (After  Smith  and 
Quincy.)  AR,  Anterior  nerve-roots  (healthy).  I,, 
Lateral  column  (diseased)  PR,  Posterior  nerve- roots 
(diseased).  P,  Posterior  columns  (diseased).  C,  Central 
canal. 


POSTEEO-LATERAL  SPINAL  SCLEROSIS. 


595 


talipes  equino-varus  ;  and  extreme  flexion  of  tlie  hands,  wrist,  forearm, 
and  head.  She  could  neither  pick  up  objects  from  her  lap  nor  hold  them 
when  placed  in  her  grasp. 

Differential  Diagnosis. — This  disease  might  possibly  be  mistaken  for 
lead-poisoning,  cerebellar  disease,  cerebro-spinal  sclerosis,  lateral  spinal 
sclerosis,  amyotrophic  lateral  spinal  sclerosis,  locomotor  ataxia,  chronic 
myelitis,  and  progressive  muscular  atrophy. 

Many  of  the  tables  given  in  connection  with  these  diseases  will  aid 
the  reader  in  making  the  necessary  discriminations. 

I  take  the  liberty  of  quoting,  however,  in  this  connection,  several 
paragraphs  from  a  late  brochure  of  W.  E.  Smith,  respecting  the  clinical 
distinctions  which  seem 
to  be  regarded  by  him 
as  justified  by  the  some- 
what scanty  literature  of 
this  subject.     He  says  : — 

"  Now,  although  it  is 
true,  as  Ormerod  has  said, 
that  there  have  been  cases 
of  Friedreich's  disease, 
so-called,  where  paralysis 
of  tlie  lower  limbs  has 
been  reported,  'in  no  case 
has  it  been  observed  until 
the  disease  had  existed 
for  a  period  of  years,  and 
in  some  very  carefully 
observed  cases  there  has 
been  no  paresis  at  all,  but 
simply    ataxia.       Again, 

although  in  some  cases  diminution  of  sensibility  has  been  noted,  it  is 
usually  for  the  earlier  periods  in  quite  an  insignificant  degree,  and  in 
many  cases  every  abnormality  of  sensation  has  been  thoroughly  excluded. 
We  have,  therefore,  in  tliis  disease  an  illustration  of  ataxia  pure  and 
simple,  apart  from  motor  or  sensor^'  paralysis.' 

"  Clinically  speaking,  the  difference  between  the  classic  locomotor 
ataxia  and  the  so-called  hereditary  ataxia  may  be  distinctively  arranged 
into  three  general  groups.  In  the  first  place,  ordinary  tabes  does  not 
run  in  family  groups,  while  Friedreich's  disease  clearly  does.  Yet  the 
cases  are  few  where,  even  in  tlie  latter  disease,  a  strict  heredit}'  can  be 
claimed.  It  attacks,  as  a  rule,  members  of  the  same  generation  in  the 
same  lamily,  although  occasionally  successive,  as  well  as  simultaneous, 
outbreaks  have  been  observed  in  the  same  family,  as,  for  example,  in 


Fig.  133. — Section  of  Dorsal  Region.  (After  Smith  and 
Quincy.)  AR,  Anterior  nerve-roots  (healthy).  AL, 
Aniero-lateral  column  (diseased).  PR,  Posterior  nerve- 
roots  (diseased).  P,  Posterior  columns  (diseased).  C, 
Central  canal. 


59G  LECTURES   ON   NERVOUS   DISEASES. 

Carre's  cases,  where  the  mother  of  the  seven  ataxic  patients,  her  brothers 
and  sisters  to  the  number  of  eight,  and  her  mother  were  all  ataxic;  in 
Brousse's  case,  where  the  mother  was  ataxic;  in  one  of  Riitimeyer's 
cases,  where  a  male  ancestor  five  generations  back  was  ataxic ;  and  in  my 
series  of  cases,*  where  the  father  of  the  five  affected  girls  clearly  developed 
the  disease  late  in  life.  More  often,  however,  a  remarkable  proclivity  to 
other  forms  of  disease  has  been  observed  in  these  family  forms  of  ataxia : 
'on  the  side  of  the  nervous  system,  to  chorea,  paralysis,  hysteria,  mental 
affections,  intemperance;  on  the  side  of  general  diseases,  to  phthisis.' 

"  Secondly,  ordinary  tabes  is  a  disease  of  middle  age  or  of  later  life, 
while  the  family  form  of  ataxia  develops  usuall}'  in  early  childhood. 
Friedreich  held  that  its  development  was  connected  with  the  changes  of 
puberty,  and  that  females  were  particularly  prone  to  it;  while  Ormerod 
believes  that  the  onset  of  an  acute  disease  ma}^  have  a  possible  influence 
in  its  production.  The  disease  is  unquestionably  due  to  a  lack  of  proper 
development  of  the  nervous  elements  of  the  cord  and  their  consequent 
ati'ophy,  and  it  is  worthy  of  notice  that  the  ataxic  families  are  generally 
large ;  so  that  it  may  be  that  the  rapid  production  of  children  may  have 
caused  an  imperfect  development  of  some  of  them.  At  an^'  rate,  enough 
cases  have  now  been  reported  to  show  that  sex  has  nothing  to  do  with 
either  the  development  or  the  occurrence  of  the  disease. 

"Nor  do  I  believe  that  puberty  is  a  potent  or  a  common  cause.f 
The  majority  of  cases  thus  far  reported  began  to  show  an  evident  lack 
of  development  at  as  early  an  age  as  five  or  seven  years,  and  1  ver}'  much 
suspect  that  if  these  cases  had  been  more  carefully  watched,  they  would 
be  found  never  to  have  been  as  stead}-  in  their  movements  as  were  other 
children.  At  the  age,  however,  when  the}^  would  naturally  begin  to 
romp  and  run,  the  parents  may  possibly  observe  that  tliej'  cannot  carry 
themselves  as  well  as  their  pla3-mates  can,  but  think  little  of  it  perhaps, 
until  the  onset  of  an  acute  disease,  or  the  extra  demands  which  puberty 
makes  upon  the  system  has  allowed  the  incoordination  to  develop  to 
such  an  extent  that  it  can  no  longer  be  unnoticed. 

"Thirdly,  the  absence  of  sensory  derangements  in  the  hereditary 
forms  of  ataxia  is  of  great  diagnostic  value.  In  typical  tabes,  as  is  well 
known,  the  lancinating  pains  are  usually  a  prominent  S5^mptom,  espe- 
cially in  the  early  stages,  and  are  rarely  absent  thi'oughout  the  entire 
histor}^  of  the  disease,  while  other  sensory  disturbances,  such  as  numb- 
ness and  local  anaesthesia,  frequentl}^  accompany  the  incooixlination  of 
movement.  But  in  the  majority  of  cases  of  family  or  '  hereditary  '  ataxia 
pain  is  conspicuous  by  its  absence,  until  at  least  the  disease  is  A-erv  far 
advanced  ;  although  it  is  true  that  cases  have  been  observed,  such  as  those 

*  Boxton  Med.  ami  Surr;.  Jourtial,  October  15,  1885,  p.  361. 
\Ibid.,  Februarj'  10, 1888,  p.  175. 


POSTEKO-LATEKAL   SPINAL   SCLEROSIS.  597 

of  Carre  and  Dreshfeld,  wliere  it  occurred  as  an  initial  symptom.  The 
absence  of  tlie  knee-jerk  is,  indeed,  common  to  both  of  the  forms  of 
ataxia  which  we  are  discussing,  but  the  curvature  of  the  spinal  column, 
which  occurs  so  early  and  so  markedly  in  tlie  family  form  of  the  disease, 
does  not  belong  to  the  history  of  locomotor  ataxia.  Another  critical 
diagnostic  symptom  is  the  aftection  of  tlie  speech  in  tlie  hereditary  form 
of  ataxia.  'From  a  mere  drawl,  stammer,  undue  confluence  or  undue 
separation  of  s^'llables,  the  aftectiou  may  advance  till  speech  becomes 
wholly  unintelligible.' 

"  The  highest  level  to  which  the  hereditary  disease  extends  is  marked 
in  its  clinical  aspect  by  the  symptom  of  nystagmus.  Bilateral  and 
transverse  in  its  action,  it  is  observed  only  when  the  patient  looks  at  or 
follows  an  object  intently.  Being  a  very  late  S3'mptom,  its  absence  in  a 
given  case  need  not  tell  necessarily  against  the  diagnosis  of  the  family 
form  of  the  disease.  Bed-sores  and  visceral  disturbances  never  occur, 
as  they  so  commonly  do  in  locomotor  ataxia. 

"  Seeing,  then,  how  marked  the  contrast  is  between  the  two  diseases, 
it  is  not  in  the  least  surprising  that  some  authors  should  have  denied 
altogether  the  existence  of  relationship  between  them.  Thus,  on  the  one 
hand,  Hammond  maintains  that  Friedreich's  cases  are  not  examples  of 
primary  disease  of  the  cord  at  all,  but  of  disease  of  the  medulla  or  cere- 
bellum, extending  secondarily  to  the  cord ;  while,  on  the  other  hand, 
Vulpian,  Charcot,  and  Bourneville  regard  them  to  be  simply  a  variety 
of  disseminated  sclerosis.  Although  the  affection  of  speech  and  the 
nystagmus  would  seem  to  lend  some  plausibility  to  the  latter  theory,  the 
morbid  anatomy  of  the  cases,  as  revealed  by  autopsies,  must  be  our  final 
test,  and  by  this  we  find  conclusively  that  the  disease  is  spinal,  and  not 
cerebral,  in  its  origin  ;  that  whatever  cerebral  degeneration  there  is  is 
late  and  entirely  secondary  in  its  development;  and  that,  moreover,  the 
spinal  sclerosis  is  S3'stematic,  and  not  disseminated,  in  its  character. 

"  Nor  does  the  suggestion  of  Erb  that  cases  of  tabes  may  be  grouped 
under  two  types,  the  classical  tjqje  and  the  type  described  by  Friedreich, 
seem  entirely  appropriate  when  we  come  to  look  at  the  patholog}', 
although  the  occurrence  of  forms  apparently  transitional  between  the 
two  may  give  some  reasonable  support  to  the  idea.  Such  cases  are 
those  reported  by  Carre,  where  there  was  a  well-marked  affection  of  the 
speech  and  a  distinct  heredity,  yet  where  the  disease  began  with  pains 
and  numbness  in  the  legs  and  feet;  and  those  reported  bj'  Dreshfeld, 
where  there  were  pains  from  the  onset,  and  no  affection  of  the  speech 
reported.  In  three  of  Friedreich's  own  cases,  also,  these  early  pains 
were  noticed,  and  in  Powers'  case  there  appear  to  have  been  vomitings 
at  an  early  period.  Other  aberrant  forms  are  the  two  cases  of  Seelig- 
muller  which  Friedreich  refused  to  recognize  as  of  the  same  type  as  his 


598  LECTURES   ON   NERVOUS   DISEASES. 

own  cases,  chiefly-  because  of  some  mental  peculiarities  and  the  persistence 
of  the  kuce-jerk." 

Treatment. — The  remarks  already  made  when  the  treatment  of 
locomotor  ataxia  was  considered  are  equally  ai)plicahle  to  this  disease. 

The  onl}'  unexplored  held  that  suggests  itself  to  my  mind  relates  to 
a  question  of  its  possible  causation.  The  accurate  determination  of  the 
presence  or  absence  of  some  marked  abnormality  in  the  visual  apparatus 
(the  eyes  themselves  or  the  ocular  muscles)  of  the  patients  so  attlicted, 
and  also  of  all  of  the  members  of  the  family  who  have  escaped,  might 
possibly  shed  some  light  upon  a  factor  which,  if  present  as  a  family- 
defect,  might  act  as  a  cause  of  serious  impairment  of  the  nervous 
energies  of  those  who  had  thus  far  escaped  any  of  the  serious  manifesta- 
tions of  organic  disease. 

The  proclivity  of  other  members  of  the  families,  into  which  this 
disease  has  entered,  to  functional  nervous  diseases, — such,  for  example,  as 
chorea,  hysteria,  intemperance,  mental  disturbances,  etc., — would  cer- 
tainly justify  us  in  investigating  this  point  very  carefully. 

EXOPHTHALMIC   GOITRE. 
(Graves''  Disease — Basedow^s  Disease.) 

A  peculiar  combination  of  an  abnormal  irritabilit}'  of  the  henrt.  a 
protrusion  of  the  eyes  from  their  sockets,  and  the  development  of  an 
enlargement  of  the  thj'roid  gland  (goitre),  has  been  considered  as  a  dis- 
tinct disease  since  the  original  publications  of  Graves  and  Basedow. 
The  term  "  exophthalmic  goitre  ''  is  now  commonl}-  used  in  speaking  of 
this  affection. 

Morbid  Anatomy. — The  pathology  of  this  disease  is  to-day,  as  it 
always  has  Ijcen,  a  sul)iect  upon  which  authors  of  note  differ.  Various 
morbid  conditions  in  the  brain,  spinal  cord,  and  sympathetic  nervous 
system  have  been  observed  in  connection  with  this  train  of  symptoms. 
In  some  instances,  however,  no  marked  changes  of  a  morbid  character 
have  been  found  after  death.  Man}-  of  the  symptoms  observed  during 
life  seem  to  point  to  some  form  of  disturbance  of  the  centres  situated 
within  the  medulla,  a  view  which  is  sustained  hy  Panas,  Hammond,  and 
others.  Basedow  considered  this  disease  to  be  a  manifestation  of  an 
abnormal  state  of  the  blood  analogous  to  chlorosis.  Piorry,  Bouillaud. 
and  others  have  attributed  man}^  of  the  symptoms  to  a  compression  made 
by  the  enlarged  glands  upon  the  vessels  and  sympathetic  nerves  of  the 
neck.  The  hypothesis  advanced  by  Stokes,  that  the  symptoms  depend 
primarily  upon  hypertrophy  of  the  heart  has  to-day  few,  if  any,  sup)iorters. 

The  symptoms  of  this  disease  are  believed  by  many  authors  to 
depend  primarily  upon  the  morbid  state  of  tlie  sympathetic  system.  On 
the  other  hand,  the  opponents  of  this  view  bring  forward  many  justifiable 


EXOPHTHALMIC   GOITEE.  599 

objections  to  this  conjecture,  and  ur<ie  that  sucli  a  conclusion  is  not 
supported  by  pathological  investigation  in  many  cases. 

The  view  seems  to  be  gaining  ground  that  we  are  justified  in  regard- 
ing this  form  of  disease  as  the  result  of  a  disturbed  action  of  the  medulla 
oblongata,  and  possibly  of  some  of  the  higher  centres  of  the  brain. 

The  prominence  of  the  eyeballs  is  probably  attributable  to  several 
factors.  Among  these  may  be  mentioned  an  unnatural  turgescenee  of  the 
vessels  of  the  orbit,  an  increase  of  the  fatt^^  tissues  of  the  orbit  back  of 
the  eyeball,  and  a  degeneration  or  lack  of  power  of  the  ocular  muscles 
which  allow  the  eyeball  to  bulge  forward. 

Etiology. — Among  the  factors  of  causation  of  this  disease,  undue 
excitement  of  mind  and  physical  or  mental  over-exertion  may  be  promi- 
nently mentioned.  It  has  been  known  to  follow  blows  upon  the  head. 
It  ma}^  occur  also  in  connection  with  any  condition  which  tends  to 
impair  the  quantity  or  quality  of  the  blood;  and  it  is  not  infrequently 
associated  with  evidences  of  hysteria  and  neurasthenia.  A  large  propor- 
tion of  such  cases  seems  to  occur  among  women,  a  fact  which  is  explained 
by  some  authors  as  a  result  of  the  frequency  of  debilitating  diseases, 
hemorrhages,  and  nervous  depression  in  the  female  sex.  It  occurs  most 
frequently  between  the  twentieth  and  fortieth  years  of  life. 

Symptoms. — The  first  symptoms  of  this  disease  are  usually  noticed 
as  a  disturbed  action  of  the  heart,  and  an  acceleration  of  the  pulse  of  a 
very  marked  character  (120  to  160  beats  per  minute).  At  first  the 
heart's  action  is  apt  to  be  irregular  only  when  the  patient  is  excited  or 
fatigued,  but,  later  on,  this  is  observed  to  occur  during  repose  and  inde- 
pendent of  any  known  exciting  cause.  There  are  no  physical  signs  of 
organic  disease,  but,  in  many  cases,  carotid  pulsation  and  a  ''  bruit  "  in 
the  vessels  of  the  neck  may  be  detected.  Occasionally',  a  systolic  murmur 
and  evidences  of  cardiac  hypertrophy'  may  be  observed  after  the  disease 
has  existed  for  some  time. 

After  a  lapse  of  several  weeks  or  months,  the  patient  notices  that 
the  thyroid  gland  is  gradually  becoming  enlarged.  This  enlargement,  as 
a  rule,  is  at  first  apparent  on  one  side  only.  The  arteries  which  sup])ly 
the  gland  ma}'  often  be  seen  to  be  more  or  less  enlarged  and  tortuous, 
and  a  blowing  murmur  may  be  sometimes  detected  over  the  gland.  The 
gland  tends  to  gradually  acquire  an  abnormal  hardness.  It  may  be  seen 
later  on  to  rise  and  fall  in  rhythm  with  the  pulsations  of  the  carotids. 

Simultaneously  with  or  following  the  enlargement  of  the  thyroid 
gland,  the  eyes  of  the  patient  begin  to  be  more  or  less  prominent  and  to 
assume  a  peculiar  fixed  look  that  has  been  compared  to  the  expression 
seen  in  the  ej'es  of  a  bull.  Tlie  size  of  the  palpebral  fissure  is  more  or 
less  increased  by  the  protrusion  of  the  eye,  and,  later  in  the  disease,  it 
often  becomes  difficult  or  impossible  for  the  patient  to  close  the  lids  over 


600  LECTUKES   ON   NEKVOUS   DISEASES. 

the  eyeball.  The  power  of  divergence  of  the  eyea  is  generally  more 
impaired  tlian  tliat  of  convergence.  The  upper  lid  participates  imper- 
fectly in  the  vertical  movements  of  the  eyeball.  The  cornea  may  lose  its 
sensibility  and  appear  more  or  less  glazetl  and  opaque.  Ulcerations  of  the 
eyeball  have  been  observed.  The  secretion  of  tears  may  be  rendered 
excessive.  An  unnatural  redness  and  swelling  of  the  conjunctiva  is  at 
times  observed.  The  power  of  vision  and  of  accommodation  is  not 
generally  disturbed. 

In  consequence  of  the  enlargement  of  the  tlwroid  gland,  the  voice 
may  be  altered  and  respiration  may  be  somewhat  embarrassed. 

The  general  system  is  apt  to  be  more  or  less  deranged.  A  loss  of 
appetite,  dyspeptic  symptoms,  diarrhsea,  marked  emaciation,  and  chlo- 
rosis are  not  infrequently  present  in  these  cases.  It  is  not  uncommon 
to  observe  the  development  of  dysmenorrhcea  or  a  complete  cessation  of 
the  catamenia.  Unilateral  sweating  has  been  recorded  in  quite  a  large 
number  of  cases. 

The  course  of  this  disease  is  an  exceedingly  chronic  one.  It  may 
last  for  many  years. 

Diagnosis. — In  those  cases  where  the  chief  phenomena  are  not 
very  pronounced,  some  difficulty  may  be  experienced  in  forming  a 
definite  opinion  respecting  the  character  of  the  disease.  Whenever  the 
eyeballs  are  at  all  prominent  on  both  sides,  if  the  th^-roid  gland  trans- 
mits to  the  hand  of  the  observer  when  placed  upon  it  a  peculiar  thrill, 
and  the  heart's  action  is  accelerated  and  somewhat  irregular,  we  are 
justified  in  suspecting  the  existence  of  this  afl[ection  even  in  cases  where 
none  of  these  symptoms  alone  are  very  well  pronounced. 

Prognosis. — Cases  of  this  character  seldom  prove  fatal.  Some  of 
the  later  publications  upon  this  subject  seem  to  justify  the  statement 
that  under  proper  treatment  quite  a  large  proportion  of  patients  so 
afflicted  may  be  cured.  In  almost  every  case,  there  is  reasonable  ground 
to  anticipate  marked  amelioration  of  the  symptoms. 

Treatment. — The  internal  medication  of  these  patients  should  be 
directed  toward  the  improvement  of  the  blood  by  iron ;  the  quieting  of 
the  nervous  symptoms  by  a  judicious  use  of  the  bromides  ;  the  improve- 
ment of  the  heart's  action  by  digitalis ;  and  the  contraction  of  the  blood- 
vessels by  ergot. 

All  of  these  ingredients  may  be  compounded  in  one  prescription, 
such  as  that  recommended  by  Hammond  : — 

I^.  Ferri  pyrophosphatis,  zinci  bromidi aa    5j- 

Digitalis  tincture 5v. 

Ergotie  ext f§iv. 

M.  Ft.  Mist. 

Dose,  a  teaspoonful  three  times  a  day. 

In   connection  with  this   prescription,  it   is   well   to  instruct    the 


MYXEDEMA.  GOl 

patient  to  eat  plentifully  of  animal  food,  and  to  indulge  in  moderation 
in  malt  liquors. 

Hammond  suggests  that  after  this  prescription  has  been  taken  for 
several  weeks,  it  be  changed  for  a  combination  of  strychnia  and 
phosphorus,  or  of  the  extract  of  nux  vomica  and  the  phospliide  of  zinc. 

The  electrical  treatment  of  these  patients  is,  perhaps,  more  important 
than  the  medicinal.  A  constant-current  battery  should  be  employed. 
The  positive  poles  should  be  applied  at  the  nape  of  the  neck,  and  the 
negative  poles  connected  with  a  medium-sized  electrode  should  be  placed 
in  contact  with  the  th^^roid  gland  for  about  five  minutes,  and  afterward 
stroked  up  and  down  the  neck  so  as  to  influence  the  sympathetic  cords 
and  the  pneumogastric  nerves  of  either  side.  The  latter  application 
should  not  exceed  five  minutes.  The  strength  of  the  current  should  be 
as  great  as  the  patient  can  comfortabh'  bear  during  the  application  to 
the  thyroid,  and  somewhat  less  intense  during  the  labile  applications  to 
the  sides  of  the  neck. 

Cases  of  cure  by  means  of  the  galvanic  current  have  been  reported 
by  Rockwell,  Bartholow,  and  others. 

Deep  injections  of  ergot  and  alcohol  have  been  employed  in  treating 
the  enlargement  of  the  thyroid  gland,  with  results  which  seem  to  have 
been  markedly  beneficial.  Hammond  reports  multiple  injections  into 
the  substance  of  the  gland  of  from  twenty  to  thirt.y  minims  of  the  fluid 
extract  of  ergot  daily.  1  have  had  no  personal  experience  with  this 
form  of  treatment. 

MYXCEDEMA. 

(  Cachexic  Paclnjdermique.) 

This  disease  seems  to  consist  of  an  abnormal  condition  of  the  skin, 
which  is  associated  with  a  deposit  of  a  mucoid  substance  and  a  degener- 
ation and  proliferation  of  the  connective  tissue. 

Morbid  Anatomy. — The  changes  observed  in  this  disease  are  prob- 
ably confined  at  first  to  the  skin  and  the  connective  tissue  which  binds 
it  to  the  muscles.  The  changes  in  the  skin  are  most  frequently  observed 
in  the  face ;  prominently  in  the  forehead,  eyelids,  cheeks,  nose,  and  lips. 
Moreover,  the  fingers  and  toes,  and  occasionally  the  limbs  and  trunk, 
may  also  be  affected.  The  mucoid  deposit  has  been  observed  not  only 
in  the  skin,  but  also  in  the  central  nervous  system.  By  some  authors  it 
is  believed  that  the  primary  changes  are  probably  confined  to  the  cells 
in  the  gray  masses  of  the  brain  and  cord,  although  the  exact  character 
of  such  changes  is  largely  a  matter  of  conjecture. 

Etiology. — This  condition  occurs  chiefly  among  women.  It  seldom 
develops  prior  to  the  period  of  pubert}'  or  after  the  fiftieth  year.  It  is 
thought  to  be  dependent  upon  pregnancy,  lactation,  parturition,  exposure 


602  LECTURES   ON  NERVOUS    DISEASES. 

to  cold,  anxiety,  mental  shock,  atrophy  of  the  thymus  gland,  sexual 
excitement,  and  the  "  neuroi)athic  tendency/' 

Symptoms. — A  peculiar  swelling,  Avhich  closely  resembles  oedema,  is 
first  noticed  in  the  face.  It  becomes  diHicult  to  close  the  lids  on  account 
of  their  extreme  thickening.  The  expression  of  the  face  tends  to  assume 
a  coarse  and  animal  appearance.  The  features  become  more  or  less 
stolid,  and  fail  to  express  the  emotions  of  the  patient.  The  tears  and 
saliva  are  secreted  in  excess  in  some  cases.  The  mucous  membranes 
which  line  the  mouth,  pharynx,  digestive  track,  and  larynx  may  also  be 
markedly  thickened.  The  voice  tends  to  become  more  or  less  hoarse  and 
nasal,  and  the  articulation  indistinct  and  monotonous. 

When  the  upper  extremities  are  affected,  the  liands  are  usually  more 
or  less  enlarged  and  distorted.  The  fingers  are  rendered  bulbous  at  their 
tips,  and  clumsy-  in  their  movements.  The  ability  of  the  patient  to  write 
or  sew  is  materially  interfered  with,  and  often  entirely  lost. 

The  feet  may  be  afl'ected  in  the  same  way  as  tlie  hands,  and  the 
swelling  of  the  skin  maj-,  in  some  cases,  extend  up  the  leg  and  even 
involve  the  trunk.  The  gait  of  these  patients  is  rendered  slow  and 
laborious  when  the  lower  limbs  are  seriously  involved. 

The  swelling  which  affects  the  limbs  and  the  trunk  differs  from  that 
of  cedema  (for  which  it  might  easily  be  mistaken)  by  the  fact  that 
pressure  made  by  the  fingers  does  not  leaA'e  a  pit  after  the  jjressure  is 
removed,  as  in  the  case  of  oedema.  The  reason  why  "  pitting  "  is  absent 
is  that  the  skin  and  the  cellular  tissue  beneath  it  have  a  semi-solid  con- 
sistence from  the  deposit  of  musin.  The  color  of  the  skin  has  been 
compared  to  that  of  alabaster,  or  of  a  yellowish  wax.  Tlie  bodily 
temperature  is  not  elevated.  In  manj^  cases  reported  it  has  been  some- 
what lower  than  normal. 

The  secretion  of  perspiration  and  sebacious  material  is  often 
markedl}'  decreased,  and  the  skin  may  appear  to  be  unnaturalh'  dry  and 
more  or  less  wrinkled.  Occasionally  the  hair  is  lost.  The  nails  may 
become  furrowed  and  extremeh^  brittle. 

These  patients  are  apt  to  suffer  from  a  sense  of  coldness  in  the 
affected  parts.  Other  forms  of  subjective  sensations,  such  as  numbness, 
the  creeping  of  ants,  the  feeling  as  if  the  parts  were  asleep,  tingling,  etc. 
These  are  less  common  than  the  sensation  of  coldness.  Occasionally  the 
skin  may  present  a  livid  color  or  isolated  reddened  i:)atches. 

The  mental  condition  of  these  patients  is  moi'e  or  less  affected  as  the 
disease  progresses.  The}'  may  exlribit  somnolence,  apathy,  a  loss  of 
memory,  and  inability  to  converse  as  intelligently  as  before  the  attack, 
or  to  solve  the  simjilest  mathematical  computations.  Delirium  and 
hallucinations  may  also  develop.  An  indilference  to  tiie  surroundings 
and  a  peculiar  slowness  of  speech  in  answer  to  questions  propounded  to 


MYXCEDEMA.  603 

the  patient  are  frequently  observed.  These  symptoms  may  be  attrilmted 
in  man}^  eases  to  the  fact  that  the  brain  and  spinal  cord  participate  in 
the  changes  observed  in  the  skin. 

The  digestive  functions  of  these  patients  are  usualh'  disturbed  to  a 
greater  or  less  extent.  Especially  in  the  latter  stages  of  the  attection, 
we  are  apt  to  encounter  constipation  and  dyspeptic  S3-mi)toms. 

The  course  of  this  disease  is  progressive,  and  essentially  chronic. 
Its  average  duration  is  said  to  be  about  sixteen  years. 

The  special  senses  are  not  infrequently  impaired.  The  patient  may 
state  that  objects  are  seen  with  a  blurred  outline,  or  as  if  surrounded  with 
a  halo.  In  some  cases,  double  vision  has  been  observed,  together  with  a 
slowness  of  movement  of  the  pupils  to  the  effects  of  light.  The  sense  of 
hearing,  may  be  diminished,  and  the  smell  and  taste  may  be  very  seriously 
ati'ected.  These  sjmptoms  may  be  explained  by  alterations  in  the  mucous 
membranes  of  the  nose,  throat,  and  mouth. 

Diagnosis — This  disease  might  possibly  be  mistaken  for  general 
oedema.  The  presence  of  aluminuria  (which  sometimes  exists  in  con- 
nection with  m^^xoedema)  might  tend  to  further  mislead  the  physician 
regarding  the  diagnosis  of  this  affection.  The  absence  of  pitting  upon 
pressure  over  the  swollen  parts,  the  clubbing  of  the  fingers,  and  the 
peculiar  distortion  of  the  features,  are  so  diagnostic  of  this  disease  that 
it  can  hardly  be  confounded  with  the  cedema  which  is  observed  in  con- 
nection with  kidne}'  disease,  arsenical  poisoning,  or  diseases  of  the  right 
heart  that  seriously  interfere  with  the  return  of  blood  from  the  veins. 

A  condition  of  body,  known  as  ^'■scleroderma^'''  in  which  there  is 
an  actual  hjpertrophy  of  the  skin,  might  be  mistaken  for  this  afiection. 
In  scleroderma,  however,  the  surface  of  the  skin  is  hard,  and  a  peculiar 
"  sense  of  tightness  "  exists  in  the  affected  parts.  We  do  not  encounter, 
moreover,  in  scleroderma  abnormal  mental  conditions,  nor  any  permanent 
reduction  in  the  temperature  of  the  body.  Besides,  it  is  encountered  at 
a  much  earlier  age  than  is  m3'xoedema,  cases  being  seldom  observed  after 
the  thirty-fifth  year,  according  to  Hammond. 

Prognosis. — Myxoedema  may  terminate  fatally,  although  in  most 
cases  its  progressive  course  covers  so  many  years  that  death  is  apt  to 
supervene  from  some  intercurrent  afiection.  There  is  little  hope  in  any 
case  of  arresting  the  disease. 

Treatment. — It  is  well  in  these  cases  to  support  the  general  health  by 
the  use  of  mineral  and  vegetable  tonics,  and  the  judicious  employment  of 
electricit}',  massage,  and  hot-air  baths.  In  spite  of  the  fact  that  medication 
seems  to  exert  little  if  au}-  influence  upon  the  actual  symptoms  of  the  dis- 
ease, the  preservation  of  the  strength  of  the  patient  and  the  regulation  of 
the  digestive  functions  may  possibly  postpone  the  development  of  the 
more  serious  manifestations  which  are  apt  to  occur  late  in  the  disease. 


SECTION  VII. 


ELECTRICITY    IN    MEDICINE. 


(605) 


SECTION  VII. 

ELECTKICITY   IN   MEDICINE.* 

In  the  diagnosis  and  treatment  of  nervous  diseases,  no  agent  is  more 
generally  applicable  than  electricit}'.  Its  brilliant  and  often  instantaneous 
ertects  and  the  prevalent  belief  among  the  laity  that  electricity  is  prac- 
tically identical  with  the  vital  forces  of  the  human  body  have  conduced 
largely  to  the  general  use  and  frequent  ahime  of  tliis  important  agent. 

Thousands  of  electric  batteries  are  sold  3'early  b}'  the  various  manu- 
facturers to  persons  both  in  and  out  of  the  medical  profession.  Many 
who  buy  them  are  utterly  ignorant  of  the  principles  of  their  construction, 
and  equally  so  of  the  indications  for  their  use.  A  very  large  majority  of 
the  medical  profession  possess  only  a  faradaic  battery  or  a  magneto- 
electric  machine.  They  emplo}'  such  a  battery  upon  every  case  which 
to  their  mind  requires  electricity.  A  few,  in  our  larger  cities,  own  a 
galvanic  battery  ;  but,  as  a  rule,  those  who  do  so  are  unable  to  repair  it 
themselves  when  the  connections  become  oxidized  or  when  it  fails  to  act 
from  a  multitude  of  other  causes.  In  my  experience,  it  is  very  uncom- 
mon to  meet  a  medical  practitioner  (outside  of  those  who  are  specially 
interested  in  neurology)  who  thoroughly  understands  electro-physics 
and  many  important  facts  relating  to  the  uses  for  which  special  forms  of 
batteries  are  best  adapted.  I  have  deemed  it  wise,  therefore,  to  include 
in  this  section  a  terse  and  practical  statement  of  the  more  important 
facts  which  should  be  mastered  before  the  treatment  of  disease  by 
electricity  is  attempted,  and  to  shed  some  light  upon  the  forms  of 
current  which  are  indicated  in  tlie  treatment  of  many  of  the  nervous  dis- 
eases commonly  encountered.  I  shall  include  in  tliese  remarks  some 
practical  suggestions  respecting  the  selection  of  batteries  and  tlie  care 
of  them.  The  uses  of  electricit}^  in  diagnosis,  as  well  as  its  therapeutical 
properties  in  the  treatment  of  nervous  diseases,  will  be  also  presented  in 
as  concise  a  form  as  is  coraportable  with  clearness  of  statement. 

PART  I. 

ELECTEO-PHYSICS. 

Under  this  heading  we  shall  first  discuss  the  varieties  of  electric 
currents  whicli  may  be  produced  (the  faradaic,  galvanic,  magneto- 
electric,  and  static).   We  shall  also  consider  the  construction  of  a  galvanic 

*  A  part  of  this  eectiou  has  been  issued  as  a  separate  volume  by  D.  Appletou  &  Co., 
New  York,  1886.  ■ 

(GOT) 


608  '  LECTURES   ON   NERVOUS   DISEASES. 

cell  and  its  many  modifications.  It  is  important  that  physicians  know 
the  princi[)los  of  construction  of  the  various  galvanic  cells  ottered  to  the 
profession  for  medical  uses,  as  well  as  the  advantages  and  disadvantages 
of  each  as  a  part  of  a  medical  outfit.  In  the  third  place,  the  reader 
should  be  made  familiar  with  many  new  terms  which  are  commonly'  used 
to-day  in  electrical  literature,  and  also  the  application  of  Ohm's  law  to 
electrical  problems.  Finall}',  he  should  acquire  a  familiarity  with  the 
many  attachments  to  a  battery.  These  are  essential  to  its  proper  use,  and 
their  purposes  should  be  well  understood.  Under  this  heading  I  shall 
give  some  practical  hints  respecting  the  selection,  care,  and  repair  of  an 
electrical  outfit  for  medical  purposes. 

VARIETIES   OF   ELECTRIC   CURRENTS. 

A  few  of  the  more  important  facts  relating  to  this  agent  (which  we 
are  constantly  called  upon  to  emplo}'  in  the  treatment  of  various  types 
of  disease)  should  be  thoroughly  understood  by  all  who  intend  to  use  it. 
Time  will  not  permit  of  a  detailed  description  of  the  difterent  properties 
of  electric  currents.  These  can  be  acquired  from  any  of  the  standard 
works  upon  physics.  It  is  necessar^^  moreover,  that  such  points  as  are 
presented  here  should  be  briefly  and  simply  stated. 

The  GALVANIC  CURRENT  (called  also  "  voltaism,^''  the  "  battery  current,'''' 
and  the  "  constant  current ")  is  one  which  is  derived  by  chemical  decom- 
position or  heat  from  one  or  more  pairs  of  elements  directly.  When  the 
body  is  placed  between  two  electrodes  connected  with  such  a  battery  in 
action,  the  current  traverses  the  part  of  the  body  embraced  between  the 
electrodes  before  it  returns  to  the  battery — starting  at  the  positive  pole 
(the  anode),  circulating  through  animal  tissue,  and  returning  to  the 
negative  pole  (the  cathode).  The  polarit}^  remains  unchanged  under  all 
circumstances. 

Muacular  contractions  are  produced  only  when  the  current  is  closed 
or  broken,  or  ivhen  its  intensity  is  increased.  A  very  weak  current  fails 
to  produce  muscular  contractions. 

In  connection  with  the  description  of  the  tests  employed  in  the 
diagnosis  of  nervous  diseases,  suggestions  have  been  made  by  me  which 
may  be  reviewed  in  this  connection  with  advantage.  (See  Section  II 
of  this  volume.) 

By  peculiar  arrangements  of  the  elements  of  a  battery,  the  galvanic 
current  can  be  modified  as  follows:  (1)  To  produce  heat  (cautery  bat- 
tery); (2)  to  insure  chemical  clianges  in  living  tissues  (electrolj'sis) ; 
and  (3)  to  aid  in  many  of  the  mechanical  arts,  such  as  electro-plating, 
electric  lighting,  telegrajihy,  etc. 

The  FARADAic  CURREXT  (callcd  also  i\\Q '■'■  induced'''' ov '"'' interrupted 
current  ")  ditt'ers  from  the  galvanic  in  that  it  is  an  induced  current  of 


VAKIETIES   OF   ELECTRIC   CURRENTS.  609 

high  tension,  which  is  produced  by  the  viagnetizing  and  demagnetizin(i 
of  a  bar  of  soft  iron  or  a  bundle  of  soft-iron  wires  by  means  of  a  galvanic 
current. 

The  circuit  of  the  generating  cell  is  made  to  pass  through  a  coil  of 
insulated  wire,  known  as  the  "  /leZia;,"  which  surrounds  the  iron  to  be 
magnetized,  but  it  does  not  itself  pass  to  the  electrodes  and  thus  to  the 
patient."^ 

Wlien  the  current  of  the  generating  cell  passes  through  the  helix, 
the  soft  iron  is  magnetized  and  draws  the  interrupter  in  contact  with  it.f 
This  breaks  the  circuit  and  demagnetizes  the  iron.  Tlie  interrupter  is 
then  returned  to  its  former  place  by  a  spring.  This  step  reconnects  the 
generating  cell  with  the  helix,  and  again  allows  the  iron  to  be  magnetized. 
The  interrupter  is  again  drawn  in  contact  with  it.  Thus  the  current 
is  constantly  broken  and  restored  by  a  simple  device  known  as  the 
"interrupter,"  or  "automatic  circuit-breaker."  An  induced  current 
within  the  iron  core  of  the  helix  is  thus  produced.  This  is  the  current 
which  passes  through  the  electrodes  to  the  patient. 

Much  ingenuity  has  been  shown  in  the  construction  of  the  "  inter- 
rupter "  of  a  faradaic  machine.  It  is  very  desirable  that  slow  and  rapid, 
interimptions  may  be  produced  at  the  will  of  the  operator.  If  a  machine 
only  insures  rapid  interruptions,  the  slow  interruptions  can  be  effected 
by  the  use  of  an  "  interrupting  electrode." 

The  power  of  producing  electrolysis,  and  some  other  chemical 
properties  peculiar  to  the  galvanic  current,  are  wanting  in  the  faradaic. 

Never  attempt  to  combine  a  galvanic  and  a  faradaic  battery.  Separate 
cells  should  be  employed  for  each,  as  the  faradaic  battery  requires  a  cell 

*  This  is  a  point  which  cannot  be  too  stronijly  impressed  upon  the  minds  of  the  pro- 
fession. Its  accuracy  can  be  readily  proved.  If  the  binding-posts  ol  the  primary  coil  of  a 
faradaic  macliine  be  united  by  means  of  a  large  copper  wire,  the  current  generated  in  the 
galvanic  cell  which  runs  the  interrupter  will  pass  through  the  wire  rather  than  through 
the  helix  which  surrounds  the  iron  core  (because  the  wire  affords  less  resistance).  The 
interrupter  will  then  remain  stationary,  as  the  iron  core  is  no  longer  magnetized.  Again, 
the  interrupted  or  faradaic  current  has  no  chemical  properties.  This  would  not  be  the 
case  if  the  current  of  the  generating  cell  passed  to  the  binding-posts  of  the  faradaic 
machine.  Finally,  the  external  resistance  of  the  human  body  is  far  in  excess  of  that 
afforded  by  the  helix,  and  this  alone  would  prevent  the  galvanic  current  of  the  generating 
cell  from  traversing  the  animal  tissues  (the  circuit  of  the  greatest  resistance). 

It  is  not  uncommon  for  agents  of  the  various  manufacturing  companies  to  show  a 
prospective  purchaser  of  a  faradaic  machine  the  galvanic  cell  which  works  the  "inter- 
rupter," and  to  endeavor  thus  to  leave  the  impression  that  a  galvanic  current  (as  well  as 
the  primary  and  secondary  faradaic  currents)  can  be  conveyed  by  a  faradaic  machine  to  a 
patient.  Such  a  statement  is  untrue,  and,  if  made,  indicates  either  ignorance  or  dishonesty. 
Subsequent  diagrams  will  render  the  mechanism  of  a  faradaic  machine  intelligible  to  the 
reader. 

t  The  expression  "  in  contact "  is  not  strictly  correct.  The  interrupter  never  actually 
touches  the  iron  core,  because  its  magnetic  action  ceases  before  it  reaches  it. 

39 


610 


LECTURES   ON   NERVOUS   DISEASES. 


Of  greater  capacity  than  those  used  in  portable  galvanic  machines. 
They  may  be  placed  in  the  same  case,  bnt  each  shouUl  be  perfectly 
independent  of  the  other.  If  a  battery  is  designed  for  transportation, 
it  is  best  to  have  one  of  each  ratlier  than  two  combined  in  one  case. 


Fig.  134. One  of  the  M.\ny  Forms  of  Faradaic  Machine — BB.  connecting  rods  attached 

to  the  elements  of  the  excilina  cell  :  D.  a  drip-cuo,  in  which  the  zinc  elemetit  is  placed  when 
not  in  use  (it  should  contain  mercury):  E,  primary  and  secondary  coils  ,  F,  adjustins;  screw 
for  the  interrupter  (7);  G,  bindin.a-posts;  /v.  plun-er;  A,  .1/,  rheophores  ;  O,  j",  electrodes 
The  next  tigure  will  explain  the  action  of  the  difterent  parts  The  faradaic  instruments  of 
different  manufacturers  vary  more  or  less  in  their  mechanicaldevicesand  perfection  of  work- 
manship, but  the  principle  of  all  is  the  same. 

'Yhe  faradaic  current  is  an  alternatinrf  current, — i.e..,  one  which  goes 
in  opposite  directions  at  each  make  and  break  of  the  circnit.  It  is 
stronoest  when  the  current  is  In-oken.  These  facts  ai-e  not  generally 
recoo-nlzed  by  the  profession.     The  polarity  changes  with  each  interrup- 


VARIETIES   OF   ELECTRIC   CURRENTS. 


611 


tion.  The  so-called  "  cathode  "  of  a  faradalc  battery  is  felt  the  strongest 
by  the  patient. 

The  helix  of  a  faradaic  machine  is  usnally  surrounded  by  a  secondar}^ 
coil  of  wire,  known  as  the  "  secondary  helix.'''' 

This  coil  has  no  connection  ivith  the  elements  of  the  generating  cell. 
The  current  produced  within  it  is  induced  by  the  passage  of  the  current 
(formed  within  the  generating  cell)  through  the  "primary  helix,"  which 
magnetizes  and  demagnetizes  the  iron  core.  It  is  therefore  called  the 
"■secondary  current.''''  It  has  high  tension,  is  alternating,  and  is 
employed  in  telephonic  lines,  chiefly  on  account  of  its  high  intensity.    It 


Fig.  135. — A  Diagram  designed  by  the  Author  to  illustrate  the  Construction  and 
Action  of  a  Faradaic  Machine. — Z,  zinc  element ;  C,  carbon  element ;  P,  binding  posts 
for  the  primary  coil;  S,  binding-posts  of  the  secondary  coil ;  a,  the  interrupter  when  the 
circuit  is  passing  to  the  heli.x  :  ^,  the  interrupter  when  the  circuit  is  broken.  The  screw 
(shown  in  contact  with  a)  allows  of  the  adjustment  of  the  interrupter  to  the  bundle  of  soft- 
iron  wires  within  the  primary  heli.x,  thus  making  the  interruptions  fast  or  slow  at  the  will 
of  the  operator.  The  patient  is  connected  with  the  battery  in  action  by  means  of  cords 
attached  to  the  binding-posts  at  P or  S.  These  cords  are  not  shown  in  the  diagram,  but  are 
shown  in  Fig.  134.  The  arrows  show  the  direction  of  the  currents.  The  zinc  is  marked  as 
the  negative  element  ( — )  and  the  carbon  as  the  positive  ( + )  element  of  the  battery.  Note 
that  the  wire  of  the  primary  coil  is  represented  as  coarser  than  that  of  the  secondary;  that 
the  secondary  coil  has  no  connection  with  the  elements  of  the  cell ;  that  the  current  going  to 
the  primary  binding-posts  is  generated  by  the  iron  core,  and  is  not  that  which  originate's  in 
the  galvanic  cell;  and  that  the  interrupter  has  a  small  piece  of  platinum  soldered  upon  it 
where  it  conies  in  contact  with  the  screw,  so  as  to  prevent  oxidation  at  that  point.  Patients 
feel  the  current  made  by  the  "break"  more  than  that  from  the  "make"  of  the  circuit; 
hence,  one  electrode  apparently  gives  a  stronger  current. 


is  modified  in  strength  by  regulating  the  amount  of  the  secondar}^  coil 
which  overlaps  the  primary — the  smaller  the  extent  of  the  overlap,  the 
weaker  the  current.  A  sliding  tube  of  metal  is  sometimes  made  to  pass 
over  the  primai-y  coil,  or  between  it  and  the  primary  coil.  This  accom- 
plishes the  same  results  as  if  the  helix  was  movable. 

The  primary  and  secondary  coils  of  a  faradaic  machine  are  made  of 
wire  of  different  thickness  and  length.  Many  of  those  sold  are  poorly 
constructed.  They  are  the  most  important  features  of  the  instrument, 
and  should  be  made  with  the  greatest  care  and  of  the  best  materials.  A 
fine  finish  of  brass  mountings  and  varnish  does  not  alwa^'s  indicate  o-ood 
workmanship  in  the  coils  themselves. 


612 


LECTURES   ON  NERVOUS   DISEASES. 


Induced  currents  develop  in  the  individual  coils  of  tlie  wire  forming 
the  primar}^  spiral  (as  well  as  in  the  iron  core  which  it  invests)  and  also 
in  the  secondar^^  helix.  These  currents  are  of  no  therapeutical  value 
without  the  iron  core,  as  they  lack  sufficient  intensity. 

If  the  secondary  helix  is  composed  of  very  fine  wire,  the  current 
induced  within  it  is  extremely  painful.  The  number  of  coils  and  the 
thickness  of  the  wire  selected  for  the  primary  and  secondary  helix 
should  he  graduated  to  a  proper  relation  to  each  other  and  the  electro- 
motive force  of  the  generating  cell  employed. 


Fig.  136. — A  Static  Machine  in  Use. —  The  "direct  spark"  is  here  represented  as  being 
drawn,  /  e.,  the  patient  being  charged  positively  and  the  electrode  being  connected  with  the 
negative  pole  of  the  machine.  No  I.eyden  jars  are  employed  in  this  form  of  administration 
of  static  electricity.  The  "  indirect  spark"  is  more  commonly  employed  than  the  direct, 
one  pole  being  attached,  in  this  case,  to  the  insulated  platform,  the  other  being  grounded  by 
a  brass  chain,  and  the  electrode  being  grounded  by  a  chain  attached  to  a  gas-pipe,  a  water- 
faucet,  or  the  like. 

The  term  '■'■  priTnarij  current  "  is  often  used  as  sjmon^-mous  with  the 
galvanic.  It  is  incorrectly  applied  l)y  some  authors  to  that  faradaic 
current  which  is  induced  by  the  magnetizing  and  demagnetizing  of  the 
soft-iron  core  of  the  helix. 

Static  electricity  is  derived  from  friction,  A  revolving  plate,  or 
by  preference  several  plates,  of  glass  may  be  employed  as  a  generator. 
Static  electricity  is  sometimes  called  frmiklinism. 

This  form  of  current  has  high  tension,  but  it  possesses  few,  if  any, 
chemical  properties,     "When  a  patient  is  charged  with  it,  it  is  necessary 


VARIETIES   AND    CONSTRUCTION   OF   GALVANIC    CELL.  613 

that  tlie  chair  upon  which  he  sits  should  be  insulated  by  glass  or  rul)ljer 
under  the  legs.  When  highly  charged,  sparks  may  be  elicited  from  the 
])ody  of  the  patient  througli  the  clothing. 

Static  electricity  will  be  quite  fully  discussed,  as  to  its  physics  as 
well  as  a  therapeutical  agent,  in  subsequent  pages. 

Experimentation  has  shown  that  this  form  of  electricity  is  accumu- 
lated upon  the  periphery  of  the  object  charged  (as  explained  in  all  works 
upon  i)hysics).  It  apparently  does  not  permeate  ver}'  deeply  below  the 
surfiice. 

The  MAGNETO-CURRENT  (called  also  the^^ dynamic  current'''')  is  derived 
from  a  permanent  or  electro-magnet,  in  front  of  which  an  armature  is 
made  to  revolve.  The  armatures  are  composed  of  a  core  of  soft  iron 
wound  with  insulated  wire,  and  the  currents  produced  are  formed  within 
them  by  breaking  the  lilies  of  magnetic  force. 

The  stronger  the  magnet,  the  more  rapid  the  breaks  made  in  the 
current  by  the  revolving  armatures,  and  tlie  greater  the  number  of  turns 
in  the  spiral  wire  of  the  armatures,  the  more  intense  is  the  current. 

This  form  of  current  possesses  great  electro-motive  force  or  intensity. 
Currents  of  this  kind  are  of  an  alternating  character.  By  means  of  an 
automatic  commutator  (polarity  changer),  they  may  be  carried,  however, 
in  one  direction,  and,  when  so,  the}'  assume  properties  similar  to  those 
of  galvanic  currents.  Electric  lighting,  electro-plating,  and  many  other 
similar  applications  to  the  mechanical  arts,  are  to-day  accomplished  by 
means  of  dynamo  machines  at  a  minimum  cost  as  compared  with  battery 
currents.  They  are  practically  obsolete  as  a  machine  for  medical  pur- 
poses, as  the  current  is  unsteady  when  hand-power  is  employed, 

"  Magneto-current "  machines  (which  are  turned  b}'  a  crank  when  in 
use)  are  often  sold  to  physicians.  They  are  of  little  value.  They  cost 
as  much  as  a  good  faradaic  instrument,  and  are  not  to  be  compared  with 
the  latter.  The  current  generated  in  both  is  practically  the  same,  but  it 
is  irregular  in  point  of  strength  in  the  magneto-current  machine,  and 
uniform  in  the  faradaic  instrument, 

THE  GALVANIC  CELL — ITS  VARIETIES  AND  THE  GENERAL  PRINCIPLES. 
OF   ITS   CONSTRUCTION. 

All  substances  have  an  electrical  condition  which  is  inherent  or 
capable  of  being  developed.  This  condition  is  known  as  the  "  poten- 
tial "  of  a  body.  The  electrical  condition  of  the  earth  (which  may  be 
regarded  as  fixed  and  as  a  reservoir  without  limit)  is  used  as  a  standard 
of  comparison  of  the  "  potential  "  of  any  given  substance. 

Those  bodies  from  which  electricity  tends  to  flow  toward  the  earth 
are  known  as  ^^  positive  bodies  "  or  bodies  of"  high  potential.''^  They  nre 
designated  by  the  plus  sign  (+).     Those  which  tend  to  draw  electricity 


G14 


LECTURES   OK    NERVOUS   DISEASES. 


from  the  earth  are  called  "  negative  bodies  "  or  bodies  of  "  loiv  potential,'''' 
and  are  desis^nated  with  the  negative  sign  ( — ).  Almost  every  known 
s-nhstance  may,  therefore,  be  classilied  either  as  positive  or  negative 
under  certnin  circumstances.  Subsequent  explanations  will  make  this 
more  apparent. 

When  we  speak  of  the  "  relative  potential  "  of  two  bodies,  we 
mean  the  difference  in  degree  of  the  potential  of  each. 

The  bodies  thus  compared  must  both  be  positive  or  negative.  One 
metal,  for  example,  may  have  a  potential  seventy  times  that  of  the 
earth,  and  another  one  hundred  times  that  of  the  earth.  Both  may  be 
positive,  yet  one  is  negative  as  compared  with  the  other.  Two  such 
metals  have  been  happily  compared  to  reservoirs  at  different  levels 
(De    Watteville).     The    tendency    between     two    bodies     of    different 


Fig.  137. — A  SimpleGalvanic  Element.  (AfterErb.)  ^/,  zinc  element;  0<,  carbon  or  copper 
element.  The  fluid  is  composed  of  diluted  sulphuric  acid  or  a  solution  of  some  of  the  salts. 
In  A  the  circuit  is  open,  in  B  it  is  closed  by  a  wire  connecting  the  elements.  The  arrow 
shows  the  direction  of  the  current  outside  of  and  within  the  cell. 


relative  potentials  is  for  the  current  to  flow  from  the  body  having  the 
highest  potential  to  that  possessing  the  lowest  potential,  thus  tending  to 
establish  an  equilibrium  between  them.  In  a  galvanic  cell,  the  element 
most  corroded  by  the  fluid  of  the  cell  has  the  highest  potential  (positive 
element). 

The  diff"erence  in  equilibrium  between  the  "  potentials  "  of  two 
bodies  regulates  the  intensity'  of  what  is  known  as  the  "  electro-motive 
force"  of  the  bodies  selected;  because  the  want  of  equilibrium  is  the 
force  which  starts  the  flow  of  an  electric  current  in  all  cases.  The  size 
of  the  elements  has  nothing  to  do  with  it. 

The  simplest  form  of  a  galvanic  (^ell  consists  of  two  bodies  (whose 
potentials  differ  widely)  immersed  in  a  fluid  which  tends  to  excite 
chemical  decomposition  of  one  of  the  elements.     Zinc  and  carbon  are 


VARIETIES   AND   CONSTRUCTION    OF   GALVANIC   CELL.  615 

commonl}-  selected  for  the  elements  and  dilute  sulphuric  acid  for  the 
exciting  agent.  The  zinc  is  strongly  acted  upon  by  the  fluid,  while  the 
carbon  is  not ;  hence,  the  zinc  becomes  the  positive  element  and  the 
carbon  the  negative.  In  most  batteries  of  this  type  the  zinc  is  covered 
with  mercury  (amalgamated),  to  render  the  action  of  the  cell  more 
uniform  and  to  prevent  local  action  upon  the  zinc.  It  also  tends  to 
preserve  the  zinc. 

An  apparently  discordant  fact  should  be  remembered,  i.e.,  that  the 
wire  connected  with  the  carbon  of  such  a  cell  (the  negative  element  of 
the  cell)  is  the  positive  pole  of  the  battery.  This  is  because  the  electric 
current  passes  through  the  liquid  from  the  zinc  to  the  carbon,  and  back 
through  the  external  circuit  from  the  carbon  to  the  zinc,     (Fig.  137,  B.) 

When  the  elements  of  a  cell  are  connected  externally  by  a  wire,  a 
current  of  electricity  flows  continuously  from  the  cell-elements  through 
both  the  wire  and  fluid.  This  is  known  as  a  "  complete "  or  "  closed 
circuit.'''' 

The  RESISTANCE  offered  to  the  passage  of  the  current  from  the  carbon 
to  the  zinc  is  the  "  external  resistance  " ;  that  between  the  ziiic  and  the 
carbon  is  known  as  the  "  internal  resistance  "  of  the  cell. 

The  INTERNAL  RESISTANCE  of  a  galvauic  cell  may  be  modified  as 
follows:  (1)  by  the  distance  between  the  elements;  (2)  by  the  size  of 
the  elements;  (3)  by  the  intervention  of  some  foreign  body  (such  as  a 
porous  cup)  between  the  elements;  and  (4)  by  the  character  of  the  fluid 
in  which  the  elements  are  immersed.  The  nearer  the  elements  are 
placed,  the  larger  their  size,  the  more  direct  the  passage  of  t'he  current, 
and  the  better  the  conducting  power  of  the  fluid  used,  the  less  the 
internal  resistance  of  the  cell,  and  vice  versa.  The  internal  resistance 
of  a  cell  may  vary  between  a  fraction  of  an  ohm  and  one  hundred  ohms, 
according  to  its  construction  and  its  excitants. 

The  EXTERNAL  RESISTANCE  is  modiflcd  by  the  length,  the  diameter:^ 
and  the  character  of  the  conductor  employed.  When  any  substance 
(such  as  the  human  body,  for  example)  is  placed  between  the  electrodes, 
the  resistance  offered  to  the  passage  of  a  current  by  the  interpolated 
substance  must  be  added  to  that  afforded  by  the  conductors  themselves. 
The  resistance  of  the  human  body  varies  from  600  to  18,000  ohms.  It  is 
extremely  low  in  subjects  aflllicted  with  general  anasarca — probably 
because  an  excess  of  fluid  renders  the  bod}'  a  good  conductor.  The 
average  resistance  of  the  human  body  is  not  much  above  2500  to  3500 
ohms.  The  resistance  afforded  by  the  body  is  modified  (1)  by  the 
saturation  of  the  electrodes;  (2)  by  the  moisture  of  the  surface  of  the 
body ;  (3)  by  the  tissues  through  which  the  current  is  directed  ;  (4)  by 
pressure  made  upon  the  electrode;  and  (5)  by  many  other  foctors  which 
will  be  mentioned   hereafter,  amons:  which   the  addition  of  salt  to  the 


616  LECTURES   ON   NERVOUS   DISEASES. 

water  in  wliicli  the  electrodes  are  moistened  is  a  very  inii)ort:uit  one.* 
In  cautery  l)atterie.s  the  external  resistance  ir.  increased  about  ^l^  for 
every  degree  centigrade  when  the  teuii)erature  of  the  platinum  wire  is 
raised  (De  Watteville),  Thus  heat  may  be  a  factor  in  modifying  the 
external  resistance  to  be  overcome. 

The  relative  resistance  of  living  tissues  is  represented  ])y  the  following 
figures  (100  being  taken  as  the  maximum)  :  The  eye,  4  ;  muscle,  6;  nerve, 
10;  cartilage,  20;  tendon,  20;  fat,  75;  bone,  100;  skin,  100.  Thus,  the 
eye  offers  only  ^^  the  resistance  afforded  by  skin  and  bone;  muscle,  -,'^1;  ; 
nerves,  ^^o;  cartilage  and  tendon,  i;  and  fat,  |.  The  epidermis,  when 
dry,  is  practically  a  non-conductor  of  electrical  currents. 

Respecting  this  point,  De  Watteville  happily  remarks  that  "the 
human  body  may  be  compared  to  a  vessel  bound  with  a  poorly-conducting 
material  (the  skin),  unequally  packed  with  non-conducting  solid  particles, 
the  interstices  being  filled  up  with  a  saline  fluid  of  fair  conductive  power. 
The  parts  most  densel}-  packed  with  solid  particles  are  represented  by 
the  bones;  those  where  liquid  predominates,  by  the  muscles.  Between 
the  two  are  found  the  nerves,  viscera,  etc." 

Before  we  leave  the  discussion  of  the  various  forms  of  electric  cur- 
rents emplo3'ed  in  medicine,  it  may  be  well  to  impress  upon  3'our  minds 
some  of  the  more  important  facts  relating  to  faradaism  and  galvanism 
by  means  of  a  table  in  which  the  two  are  contrasted  with  each  other. 
Such  a  table  is  not,  to  my  knowledge,  to  be  found  in  an}'  work  upon 
electricit}'.     It  may  prove  of  service  in  many  ways  : — 

THE  FARADAIC  CURRENT  THE  GALVANIC  CURRENT 

Is  an  "  induced  current."     Is  produced  Is  due  to  chemical  decomposition  of  one 

by  the  magnetizing  and  demagnetizing  of  or  more  of  the  elements  of  a  galvanic  cell. 
a  core  of  soft  iron. 

Its  polarity  changes  with  each  "  make"  Its  polarity  is  constant.     The  negative 

and  "break"  of  the  circuit.  element  of  the  cell   becomes  the   positive 

pole  of  the  battery. 

The  current  is  an  interrupted  one.  The  current  is  a  continuous  one. 

It  produces  muscular  contractions  of  It  does  not  produce  muscular  contrac- 

an    apparently   continuous   character,  pro-  tions,  except  when  the  intensity  is  increased 

vided  the  interruptions  are  very  rapid.  or  wlien  the  circuit  is  made  or  broken. 

The  polarity  is  inconstant,  because  the  Each  pole  has  a  special  therapeutical 

currents  constantly  alternate  in  direction.  action  peculiar  to  it  under  all  circumstances. 

*In  testincf  tins  point  lately  by  means  of  a  Brenner'ei  rheostat,  I  found  the  resistance 
from  right  palm  to  loft  palm,  in  a  boy  of  thirteen  years  of  age,  to  be  17,500  ohms,  when 
pure  water  was  used  and  the  electrodes  preijsed  firmly  against  the  skin  of  both  palms. 
Adding  a  tcas])oonful  of  salt  to  the  water  and  again  soaking  the  si)ongcs  reduced  the  resist- 
ance to  7.500  ohms.  Tliis  illustrates  well  tlic  necessity  for  so  simi)lc  a  precaution  when 
employing  electric  currents  upon  animal  tissues.  When  very  high  currents  arc  being 
used,  esi)ecially  in  gynecological  practice,  salt  sliould  not  be  employed  because  it  is  apt  to 
be  decomposed  by  the  current. 


VAEIETIES   AND    CONSTRUCTION   OF   GALVANIC   CELL. 


61' 


The  Faradaic  Cukkent  {coyitinued) 

Is  seldom  administered  by  the  so-called 
"polar  method." 

Wide  separation  of  the  poles  intensifies 
the  pain. 

The  "secondarj'  current"  has  greater 
penetrating  power  than  the  "  ])rimary  cur- 
rent." Neither  equals  the  galvanic  current 
in  this  respect. 

It  has  no  chemical  properties.  It  may 
be  modified  by  an  automatic  commutator, 
so  as  to  throw  its  currents  constantly  in  the 
same  direction,  as  in  a  dynamo  machine. 
In  this  case  it  possesses  chemical  attributes. 

A  galvanometer  will  show  only  one 
deflection,  i.e.,  the  difi"erence  in  strength  of 
the  "  make  "  and.  "  break  "  currents.  This 
deflection  is  the  same  under  all  circum- 
stances when  the  machine  is  in  use.  It 
does  not,  therefore,  indicate  the  strength  of 
the  current  conveyed  to  the  patient. 

There  is  no  diff'erence  in  the  action  of 
the  poles. 

The  faradaic  instrument  makes  a 
"  buzzing  noise"  when  in  action. 


The  Galvanic  Current  {continurd) 

Is  administered  chiefly  by  the  "jiolar 
method." 

Separation  of  the  poles  does  not  ma- 
terially intensify  the  pain. 

Has  a  remarkable  power  of  penetrating 
anmial  tissues  placed  "  in  circuit." 


Possesses  inherent  chemical  properties  ; 
hence  its  power  of  producing  electrolysis, 
and  its  use  in  electro-plating,  electric 
lighting,  etc. 

Produces  galvanometer  deflections 
which  are  proportionate  to  the  strength  of 
the  current  employed. 


The  anode  is  the  sedative  pole :  the 
cathode  is  the  stimulating  pole. 

A  galvanic  instrument  gives  no  ex- 
ternal manifestation  of  activity,  because  it 
has  no  interrupter. 


Electrical  Units. — Before  the  construction  of  an  electric  battery 
and  the  modiflcatioiis  in  such  an  apparatus  necessary  to  produce  special 
effects  are  considered,  it  is  important  that  you  familiarize  yourselves 
with  the  various  units  of  measurement  employed  in  electricity,  and  their 
symbols.     These  are  as  follow  : — 


THING    MEASURED. 

SYMBOL. 

NAME   EMPLOYED   FOR   UNIT. 

Quantity. 

Current. 

Electro-motive  Force. 

Resistance. 

Capacity. 

Work  or  Energy. 

Power. 

Q. 

C. 
E.  M.  F.  or  E. 
R. 
K. 
W. 
P. 

Coulumb. 

Ampere  or  Weber. 

Volt,  (contraction  of  Volta). 

Ohm. 

Farad,  (contraction  of  Faraday). 

Joule. 

Watt. 

A  COULUMB  is  the  quantity  that  passes  in  one  second  of  time  against 
one  ohm  of  resistance  under  an  electro-motive  force  of  one  volt.  We  use 
this  term  as  we  do  "  pints  "  or  "  quarts  "  in  speaking  of  fluids.  One 
coulumb  will  decompose  92  microgrammes  of  water,  and  thus  evolve 
10.4  microorammes  of  hvdrouen. 


618  LECTURES   OX   NERVOUS   DISEASES. 

An  AMPERE  is  the  current  produced  by  one  volt  against  one  ohm  of 
resistance.  In  medical  practice,  the  millinmpere  is  generally  accepted 
as  the  unit  of  current-strength.  An  ampore  will  decompose  .00142  of  a 
grain  of  water. 

A  VOLT  is  the  electro-motive  force  necessary  to  produce  a  current 
of  one  ampere  against  an  ohm  of  resistance.  It  practically  equals  the 
electro-motive  force  of  one  Daniell's  cell.  We  speak  of  a  battery  as  of 
so  mau}^  volts  just  as  we  designate  an  engine  as  of  so  many  horse-power. 

An  OHM  is  the  resistance  necessary  to  allow  of  one  ampere  of  current 
under  an  electro-motive  force  of  one  volt.  It  is  equivalent  to  a  piece  of 
telegraph-wire  one  hundred  metres  in  length  and  of  a  certain  definite 
sectional  area,  or  a  column  of  mercury  one  square  millimeter  in  diameter 
and  1.05  metre  in  height. 

A  FARAD  is  the  capacity  of  a  condenser  which  would  contain  a  charge 
of  one  coulumb  under  an  electro-motive  force  of  one  volt. 

A  JOULE  is  the  amount  of  electric  energy  absorbed  when  a  coulumb 
falls  one  volt.  It  is  equivalent  to  about  ^  of  the  heat  required  to  raise 
one  gramme  of  water  at  0.°  C.  one  degree,  or  .7373  foot-pounds. 

A  WATT  is  the  power  developed  by  one  ampere  falling  one  volt.  It 
is  equivalent  to  j^^  of  a  horse-power. 

The  prefixes  "  wegr  "  and  "'micro''''  denote  million  and  millionth. 
For  example,  a  megohm  is  one  million  ohms  ;  and  a  microhm  is  a 
millionth  of  one  ohm. 

The  names  selected  for  the  various  units  of  measurement  are  taken 
from  those  of  prominent  electro-scientists  (Ohm,  Volta,  Faraday, 
Ampere,  and  others). 

Ohm's  Law. — We  are  now  prepared  to  consider  the  law  of  electric 
currents  discovered  b}'  Ohm,  b}-  which  the  intensity  of  a  current  that 
will  result  from  any  combination  of  cells  may  be  mathematically  com- 
puted, and  many  other  electrical  problems  solved.  It  may  be  thus 
stated  : — 

Electro-motive  Force 

Intensity  of   Current  = ;    or,  if  expressed    in 

Resistance 

(Inlernal+Extei'nal) 

E 
symbols,  C  or  I  =  — —• 

Now,  in  constructing  a  batter3',the  object  to  he  attained  must  be  first 
considered,  A  battery  designed  to  produce  heat  (the  cautery  l)attery), 
for  example,  is  not  built  upon  the  same  plan  as  one  designed  for  ordi- 
narj"^  medical  purposes. 

Again,  different  cells  (such  as  those  devised  by  Daniell,  Grove, 
Leclanche,    Grenet,    Bunsen,    Smee,    Hill,  and   others)  possess   special 


VARIETIES   AND   CONSTRUCTION    OF    GALVANIC    CELL. 


619 


advantages  and  disadvantages  which  have  to  be  considei'ed  carefully 
before  a  decision  is  made  respecting  the  one  which  should  be  employed. 

Finally,  the  number  q/"  ceZZs,  the  ai'rangement  of  the  elements^  mwd 
the  size  of  the  elements  are  problems  to  be  determined  with  special 
reference  to  the  purpose  for  which  the  battery  is  designed.  These 
points  will  be  touched  upon  hereafter. 

It  is  important  that  a  few  facts  be  stated  in  the  beginning  respect- 
ing the  more  common  methods  of  connecting  and  grouping  galvanic 
cells.  Subsequently,  the  different  forms  of  cells  employed  by  well- 
known  manufacturers  of  electrical  apparatus  may  be  tersely  described 
with  advantage.  Finally,  the  various  attachments  to  an  electric  battery 
designed  for  medical  pui-poses  should  be  mentioned,  and  the  uses  of  each 
briefly  outlined. 


Fig.  138. — A  Compound  Chain.  (After  Eib.)  Three  sets  of  elements  are  here  connected 
"behind  one  another,"  or  "in  series."  The  direction  of  the  current  is  shown  by  the  arrows. 
The  circuit  of  closure  is  effected  by  a  wire,  as  in  Fig,  137,  B. 


Let  us  suppose,  for  the  purpose  of  illustration,  that  we  have  decided 
to  use  a  certain  number  of  cells  (one  of  the  numerous  forms  subse- 
quently mentioned)  in  preparing  a  battery  for  medical  use.  How  shall 
we  connect  them  so  as  to  best  accomplish  our  purpose? 

If  we  join  the  carbon  and  zinc  elements  together  (using  that  form 
of  cell  for  example),  and  continue  to  do  so  throughout  the  entire  series  of 
cells  (Fig.  138),  we  have  formed  what  is  known  as  a  '■'■compound  circuit'' 
or  an  arrangement  "in  series."  If  we  join  all  the  negative  or  carbon 
elements  together,  and  then  the  positive  or  zinc  elements  in  a  similar  way, 
we  have  what  is  known  as  a  "  simple  circuit "  (Fig.  141).  Finally,  we  may 
divide  the  cells  into  gronpis ;  then  join  those  of  each  group  in  simple 
circuit;  and  afterward  unite  these  groups  as  if  they  were  single  cells. 

Now,  what  will  the  effect  of  each  of  these  methods  of  combination 
have  on  the  intensity  of  the  current?  Ohm's  law  comes  into  play  in 
deciding  such  a  problem. 


620 


LECTUKES   ON  NEllVOUS   DISEASES. 


We  must  (iist  ascertain  tlie  internal  resistance  of  the  form  of  cell 
which  we  have  selected  for  our  battery.*  We  must  know  also  the 
external  resistance  which  we  shall  have  to  overcome  in  our  proposed 
use  of  it.  Finally,  we  must  ascertain  the  electro-motive  force  of  the 
elements  of  each  cell. 


Fig.  139. — A  Schematic  Repkesentation  op  the  Introduction  of  a  Human  Body  (a) 
INTO  THE  Circuit  of  Closure  op  a  Galvanic  Chain.  (After  Erb.)  +=the  anode; 
—  =  the  cathode. 


Suppose,  for  example,  that   E  =  l,Ir  — 20,  Er=10.     The  current 
of  each  cell  would  then  be  expressed  as  follows  : — 

1  1 

C  = =  — =  .033+. 

20+10      30 

*  To  computo  the  internal  resistance  of  a  cell  or  battery  requires  apparatus  not  erener- 
ally  owned  by  medical  practitioners,  i.e.,  a  coil  rheostat,  which  may  be  confidently 
regarded  as  accurate,  and  a  carefully  calibrated  galvanometer,  by  a  standard  maker.  The 
rule  given  by  De  Watteville,  and  copied  from  him,  apparently,  by  Aniidon,  would  be  simple 
if  it  were  true.  I  have  tested  it  again  and  again,  and  have  personally  discarded  it  us 
unworthy  of  credence.  I  have  also  had  a  professional  electrician  test  it.  He  arrived  at 
the  same  unsatisfactory  results.  The  rule  of  De  Watteville,  to  which  I  refer,  is  as  follows  : 
First  note  the  needle-deflection  of  the  cell  or  battery  to  be  tested  under  a  given  resistance, 
then  introduce  sufficient  additional  resistance  to  reduce  the  recorded  needle-deflection 
exactly  one-hulf.  The  added  resistance  will  equal  the  internal  resistance  of  the  cell  or 
battery  tested.  The  internal  resistance  of  any  cell  can  be  computed  with  accuracy  ;  but 
by  a  more  complicated  method,  described  in  most  of  the  standard  works  upon  electricity. 
Most  manufacturers  can  give  the  requisite  information  respecting  the  internal  resistance 
of  any  cell  used  by  them,  and  that  resistance,  multiplied  by  the  number  of  cells  employed, 
will  equal  the  total  resistance  of  a  battery  (the  cells  being  united  "  in  series,"  as  shown  in 
Fig.  138). 


VARIETIES  AND   CONSTRUCTION   OF   GALVANIC   CELL. 


621 


Now,  if  twenty  cells   of  this  kind  be  joined  in  "  simple  circuit,"  the 

elements  have  each  been    practically  increased  twent}^  times,  and  the 

internal  resistance  has    therefore    been    decreased    twenty  times.     The 

external  resistance  remains  the  same.     We  therefore  have 

1  1 

C= =  —  =  .0909  +. 

IB+10      11 

If  these  cells  be  now  arranged  in  "  compound  circuit,"  the  electro- 


FiG.  140, — Six  Cells  Connected  FOR  Intensity.  (After  De  Watteville.)  s,  zinc  elements  ;  c, 
carbon  or  platinum  elenient.s  This  arrangement  is  known  as  "in  series"  or  "compound 
circuit."     it  increases  the  "electro-motive  force"  of  the  battery. 


motive  force  and  the  internal  resistance  will  be  increased  twenty  times. 
We  should  thus  have  the  following  formula : — 

1X20  2 


C: 


.048+. 


20X20+10      41 

Finally,  if  the  cells  were  arranged  in  four  groups  of  five  each  in 
simple  circuit,  we  should  have  practically  four  cells  with  elements  five 
times  as  large  ;  hence,  the  internal  resistance  would  be  only  one-fifth  that 


Fig.  141. — Six  Cells  Connected  for  Quantity,  i.e.,  "in  surface,"  or  in  "simple  circuit." 
(After  De  Watteville.)  2,  zinc  elements:  c,  carbon  or  platinum  elements.  This  arrange- 
ment does  not  affect  the  "electro-motive  force  "  of  the  battery. 


of  a  single  cell  and  the  electro-motive  force  four  times  as  great, 
should  then  have  the  following  formula : — 

1X4         4       2 

C  = =  — =  - 

7 


We 


.285+. 


25" +10      14 

Remember  that  the  electro-motive  force  means  the  difference  in 
potential  of  the  cell  elements.  It  is  therefore  unchanged  by  their  size. 
A  cup  of  water  elevated  one  hundred  feet  will  produce  as  much  press- 
ure through  a  pipe  connected  with  it  (provided  that  the  cup  be  kept 


622  LECTURES   ON  NERVOUS  DISEASES. 

constantly  filled)  as  would  a  lake  ten  miles  in  circumference,  at  the  same 
elevation  and  similarly  connected  with  tlie  pipe.  So  it  is  with  electro- 
motive force.  The  size  of  the  elements  will  alter  the  quantity  of  elec- 
tricity generated  ;  but  the  electro-motive  force  of  a  cell  or  battery  will 
remain  undisturbed  by  increasing  or  diminishing  the  size  of  the  elements. 
I  frequently  hear  this  remark  made  :  "  The  cells  are  too  small  for  medical 
purposes,  are  they  not  ?"  To  this  question  I  would  reply  that  intensity 
of  current  and  moderate  quantity  are  to  be  aimed  at  in  constructing  a 
a  medical  battery. 

The  few  illustrations  which  have  been  given  show  that  the  current- 
strength  has  been  modified  in  each  instance  by  the  changes  made  in  the 
arrangement  of  the  cell-elements. 

If,  however,  we  took  a  higher  external  resistance  (as  would  be  re- 
quired in  a  medical  batter^^ — say  about  2500  ohms),  we  should  find  that 
the  simple  circuit  arrangement  made  but  little  difference  in  the  power  of 
the  current,  while  the  compound  circuit  materially  increased  the  current- 
strength.  It  is  important  to  remember,  therefore,  that  the  external 
resistance  is  an  important  factor  in  modifying  the  strength  of  the  cu?^rent, 
and  that  all  combinations  of  cells  are  not  equally  efficient. 

The  most  useful  battery  for  medical  jjurposes  is  one  which  is  planned 
with  a  view  of  making  the  internal  and  external  resistances  as  nearly  equal 
as  possible. 

When  we  wish  to  construct  a  battery  for  ordinary  galvanic  treat- 
ment^ it  is  best  to  overcome  the  high  resistances  encountered  by  using  a 
large  number  of  small  cells,  with  a  high  electro-motive  force,  coupled  in 
compound  circuit, — i.e.,  "  in  series."  The  aggregate  internal  resistances 
of  the  cells  never  will  exceed  the  external  resistance  furnished  by  the 
living  tissues. 

In  devising  a  battery  for  electrolysis,  the  arrangement  should  be 
snch  as  will  secure  simple  intensity.  The  resistance  to  be  overcome  by 
the  current  in  passing  through  small  portions  of  the  body  seldom  exceeds 
100  to  500  ohms.  A  small  number  of  cells  of  medium  size  (16  to  24  of 
Grenet's  cells),  coupled  in  compound  circuit,  will  give  us  the  desired  ends 
and  accomplish  the  best  results. 

A  cautery  battery  requires  very  large  plates,  placed  closely  together. 
In  the  "  PiflTard  battery  "  the  zinc  plates  are  perforated,  and  the  elements 
are  so  arranged  as  to  be  mechanically  shaken  in  the  fluid  while  the 
battery  is  in  action.  I  regard  this  as  the  best  instrument  of  its  kmd. 
Its  action  is  continuous,  and  the  heat  generated  may  be  maintained  at 
any  desired  temperature  by  one  familiar  with  its  management. 

The  Various  Forms  of  Cklls. — Human  ingenuit}-  has  been  strained 
to  its  utmost  for  nearly  a  century  to  devise  an  absolutely  perfect 
galvanic  cell.     Space  will  only  allow   here  of  a  brief  statement  of  the 


SPECIAL   FOKMS   OF   THE   GALVANIC   CELL. 


623 


varieties  now  in  common  nse.    The  construction  of  each  and  the  peculiar 
advantages  and  disadvantages  of  each  will  be  also  tersely  mentioned. 

SPECIAL   FOKMS   OF   THE   GALVANIC   CELL. 

All  forms  of  galvanic  cells  may  be  classed  under  one  of  three  groups, 
as  follows:  (1)  one-fluid  cells,  with  no  depolarizer;  (2)  one-fluid  cells, 
with  a  solid  or  liquid  depolarizer;  (3)  two-fluid  cells. 

Each  of  these  three  varieties  has  many  modifications,  which  are 
commonly  named  after  the  inventor.  A  few  of  each  only  need  to  be 
mentioned. 

I.  One-fluid  Cells,  with  no  Depolarizer. — The  elements  of  this 
group  are  all  immersed  in  a  fluid  to  which  nothing  has  been  added  to 
prevent  polarization  (i.e.,  the  formation  of  bubbles  of  hydrogen  on  the 
negative  and  of  oxygen  on  the  positive  element  of  tlie  cell  during  its 
period  of  activity). 

Smee''s  Cell  (1840). — Perhaps  the  best  of 
this  group  is  that  devised  b^-  Smee.  It  consists 
of  two  zinc  plates  with  one  of  j^latinized  silver, 
suspended  between  the  zincs,  immersed  in  di- 
luted sulphuric  acid.  The  electro-motive  force 
is  about  .47  volt. 

Walker's  Cell  (1859).— Platinized  carbon 
is  used  in  place  of  platinized  silver.  It  is 
cheaper  than  Smee's  cell.     E.  M.  F.  =  .66  volt. 

II.  One-fluid  Cells,  with  Solid  Depolar- 
izers.— The  best  of  this  group  is  the  cell  devised 
by  Leclanche. 

Leclanche's  Cell  (1868).— The  carbon  ele- 
ment is  ])acked  in  a  porous  cup,  with  the  needle 
form  of  the  black  oxide  of  manganese  surround- 
ing it.  This  cup  is  then  placed  in  a  glass  vessel, 
containing  a  rod  of  zinc  and  a  solution  of  sal.  ammoniac.  The  cup  is 
carefully  sealed  to  prevent  evaporation  and  escape  of  its  contents. 
E.  M.  F.  =  1.48  volt,  when  the  battery  is  not  polarized. 

3lai'ie-Davy  Cell. — Amalgamated  zinc,  acidulated  water,  carbon, 
and  a  paste  of  sulphate  of  mercury.     E.  M.  F.  =  1.52  volt. 

Agglomerate  Leclanche  Cell. — The  carbon  is  surrounded  by  plates 
of  a  special  composition,  which  are  bound  around  it  by  India-rubber 
bands.  The  internal  resistance  can  be  intensified  by  adding  plates  as 
.desired.  E.  M.  F.  ^  1.48  volt.  The  internal  resistance  with  three 
plates  =1.8  ohm ;  with  two  =  1.4  ohm ;  with  one  =  .9  ohm. 

III.  One-fluid  Cells,  with  Liquid  Depolarizers. — Of  this  group 
the  Grenet  cell  is  the  most  used  for  medical  purposes. 


Fig.  142. — Smee's  Cell. — This 
is  a  favorite  with  some  manu- 
facturers for  a  portaljle  faradaic 
machine.  In  the  author's  opin- 
ion, it  is  far  less  satisfactory 
than  Fuller's  cell  if  the  battery 
is  a  permanent  one,  or  a  Grenet 
cell  if  the  battery  is  designed 
for  transportation.  It  is  active 
at  first,  but  weakens  rapidly 
from  polarization. 


624 


LECTUKES  ON  NERVOUS  DISEASES. 


GreneVs  Cell. — The  elements  are  two  i)lates  of  carlion  and  one  zinc 
plate  (amalgamated).  The  zinc  element  can  be  lowered  into  the  tliiid  or 
raised  at  will.  It  lies  between  the  carbons.  The  depolarizer  is  l)ichro- 
mate  of  potassium.  The  active  constituent  of  the  fluid  is  dilute  sulphuric 
acid.  These  two  ingredients  form  what  is  known  as  the  "  red-acid  fluid." 
These  cells  are  of  different  sizes. 

Trouve's  Cells  (1875).— Similar  to  Grenet's,  but  of  large  size.  E. 
M.  F.  ==  2  volts.     The  internal  resistance  varies  from  .00 IG,  when  first 


Fig.  143. — Leclanchf.'s  Cell. — The  zinc  rod  (the  one  with 
its  rheophore  attached)  is  shown  as  immersed  in  a  solution 
of  ammonic  chloride.  The  carbon  element  is  seen  to  project 
slightly  above  the  porous  cup,  in  which,  when  the  cell  is 
properly  prepared  for  action,  it  is  packed  with  peroxide  of 
manganese  and  afterward  covered  with  pitch. 


Fig  144. — Grenet's  Cell. — The 
flasks  come  of  all  patterns, 
according  to  the  taste  of  the 
various  makers.  In  the  form 
here  depicted  the  zinc  is 
lowered  into  the  fluid  by  a 
straight  handle.  This  is  the 
cell  most  used  in  portable 
electrical  apparatus.  It  is 
cheap,  eflScient,  and  easily 
repaired.  Kenioving  the 
elements  and  replacing  them 
overcomes  "polarization"  in 
case  the  current  grows  weak 
from  that  cause.  Some 
makers  place  the  zinc  inadrip- 
cup  when  the  cell  is  not  in  use. 


set  in  action,  to  .07  after  the  "  spurt."  The  plates  are  raised  and  lowered 
by  a  windlass.  The  extent  of  immersion  can  thus  be  graduated.  This 
form  of  element  is  known  as  a  "  plunge  batter^'." 

Fuller''s  Cell. — A  porous  cup  containing  zinc,  mercury,  and  water  is 
placed  in  a  large  glass  jar  containing  red-acid  fluid,  in  which  a  large 
carbon  plate  is  immersed.  The  mercury  keeps  the  zinc  amalgamated. 
The  elements  are  not  removed  when  the  cell  is  not  in  action.  This 
form  of  cell  is  perhaps  the  best  one  yet  devised  to  run  the  faradaic  part 
of  a  cabinet  battery. 


SPECIAL   rOEMS   OF   THE   GALVANIC   CELL. 


625 


ly.  Two-fluid  Cells. — In  tliis  group,  the  Duniell,  Grove,  and  Biinsen 
cells  are  the  most  used.  The  two  latter  are  not  well  adapted  for  medical 
purposes.  The  fumes  which  arise  from  some  of  them  are  unpleasant. 
D^aiamos  are  now  generally  substituted  for  them  in  the  mechanical  arts. 

DanieWs  Cell  (1836). — The  so-called  "sulphate  of  copper"  cells 
(of  various  t3qies)  are  modifications  of  that  devised  by  Daniell.  The 
elements  are  zinc  and  copper,  separated  in  the  original  form  hy  a  porce- 
lain or  baked-clay  diaphragm.  The  zinc  is  immersed  in  dilute  sulphuric 
acid,  and  the  copper  in  a  saturated  solution  of  sulphate  of  copper.  K. 
M.  F.  ^  1.0T9  volt.  The  solution  for  the  zinc  element  maj'  also  be  pure 
water,  salt  and  water,  or  a  solution  of  sulphate  of  zinc. 


QSiQil^ 


Fig.  14.1— Fi'llek's  C  ei.l. — This  is  the 
best  cell  ( in  the  opinion  of  the  author) 
to  use  in  connection  with  a  permanent 
faradaic  machine.  It  is  not  well 
adapted  for  transportation. 


Fig.  146. — Siemens  anu  HAL^Kt;'s  Cell  —  I  his 
cell  is  very  efficient ,  but  it  is  expensive  to  repair 
when  the  battery  becomes  exhausted.  It  is 
highly  recommended  by  some  European  au- 
thorities for  use  in  a  cabinet  or  permanent 
office  battery.  In  this  country  the  Leclanchc 
cell  is  more  favorably  regarded. 


Siemens  and  Hahke''s  Cell. — This  is  a  favoi'ite  cell  for  medical  bat- 
teries in  Europe.  It  is  a  modification  of  the  Daniell's  cell  and  is 
expensive.  A  copper  rosette  is  placed  in  a  saturated  solution  of  sulphate 
of  copper  at  the  bottom  of  the  jar ;  this  is  covered  with  a  porous 
diaphragm  packed  with  papier-mache,  on  which  the  zinc  rests  surrounded 
by  water.  Water  is  added  to  the  battery  from  time  to  time,  and  also 
crystals  of  the  sulphate  of  copper.  This  form  of  cell  is  very  constant ; 
but  it  is  extremely  difficult  to  repair  when  out  of  order.  As  a  permanent 
battery,  such  cells  may  last  a  long  time  with  proper  care  ;  but  they  often 
do  not,  as  the  cells  may  become  impaired  from  a  multitude  of  causes 
(poor  construction,  improper  iise,  etc.). 

HilVs  Gravity  Cell. — This  is  another  modification  of  the  Daniell  cell. 
It  is  used  in  medicine  by  many  neurologists.     A  copper  plate  rests  on 

40 


626 


LECTURES   ON   NERVOUS   DISEASES. 


tlie  bottom  of  the  ghiss  j:ir,  covered  witli  a  satunited  solution  of  sulpluite 
of  copper.  The  zinc  element  is  u  disk  perforated  bv  a  large  central 
opening,  through  which  crystals  of  sulphate  of  copper  may  be  dropped 
when  the  battery  is  inactive.     A  solution  of  sulphate  of  zinc  floats,  with- 


yiG.  147. — Hill's  Gravity  Cell. — This  cell  is  employed  very  extensively  in  telegraphy,  and  is 
recommended  by  some  authors  for  permanent  medical  batteries.  When  the  jars  are  well 
paraffined  at  the  top,  the  cells  do  not  "salt"  badly.  They  require  but  little  care  when  prop- 
erly set  up.  Personally,  1  prefer  a  modification  of  this  cell  (in  which  the  zinc  is  placed 
within  a  suspended  porous  cup)  to  the  one  shown  in  the  cut.  It  requires  less  care,  and  is  not 
aftected  by  agitation.     It  also  has  a  higher  internal  resistance. 

out  an  intervening  diaphragm,  on  top  of  the  copper  solution,  and 
immerses  the  zinc  disk.  This  battery  must  not  be  agitated,  as  the  two 
solutions  would  then  become  mixed.     E.  M.  F.  =  1.068. 

Grovels  Cell  (1839). — This  consists  of  amalgamated  zinc  immersed 
in  dilute  sulphuric  acid  Avithin  a  porous  pot.     Outside  of  this  pot  plati- 


FiG.  14S  — Gkovf.'s  Ceil. —  This  cell  (shown  here  in  the  form  of  a  battery)  is  not  used  in  medi- 
cal practice,  chiefly  on  account  ot  the  fumes  which  arise  from  it  If  used  in  the  mechanical 
arts.  It  is  a  very  expensive  cell  to  employ.  Dynamo  machines  have  now  taken  the  place  of 
Grove  batteries  to  a  very  great  extent. 


nam  is  immersed  in  nitric  acid  placed  in  a  glass  jai-.  E.  M.  F.  =  1.96 
volt.  The  platinum  is  bent  into  an  S-shape  to  increase  its  surface. 
Many  modifications  of  this  cell  have  been  made  for  use  in  mechanical 
arts.     The  fumes  arising  from  it  are  veiy  objectionable. 


ATTACHMENTS   TO   A   COMPLETE   BATTEKY. 


627 


^^S^aci^si' 


Fig.  H9. — Bunsen's  Cell. — Parts  are  represented 
as  bitten  away  to  show  its  arrangement  :  the 
cylinder  of  zinc  (:;) ;  a  liorous  cup  (e/);  and  the 
carbon  (c)  within  it.  'I'his  cell  is  not  employed 
in  medical  batteries,  for  reasons  similar  to  those 
given  in  connection  with  Fig.  148. 


Bunsen^s    Cell   (1840). — This  is   a  modification  of  tlie  Grove  cell. 
The  platinum  is  replaced  by  artificial  carbon  in  the   form  of  a  hollow 
C3'linder,   and    a    cylinder    of    zinc 
is   bathed  in  dilute   sulphuric  acid. 
PI  M.  F.  =  1.9  volt. 

ATTACHMENTS   TO   A   COMPLETE 
BATTERY. 

Although  it  is  not  necessary 
for  a  general  medical  practitioner 
to  have  all  of  the  attachments  to  a 
battery  such  as  ^are  employed  by 
neurological  specialists,  still  it  is 
important  that  they  be  mentioned 
here,  and  their  uses  interpreted. 
The  most  important  attachments  to 
a  cabinet  or  fixed  battery  for  office 
use    only    are    a    galvanometer,    a 

rheostat,  a  thermo-electric  diflerential  calorimeter,  a  polarit}^  changer  or 
"  commutator,"  and  a  variet}"  of  rheophores  and  electrodes.  Portable 
batteries  do  not  require,  as  a  part  of  their  construction,  the  first  three  of 
these  attachments,  but  they  should  possess  the  others. 

The  Galvanometer. — When  a  galvanic  current  circulates  in  a  coil 
of  wire  about  a  magnetic  needle,  it  causes  deviations  of  that  needle,  which 
are  modified  by  both  the  strength  and  direction  of  the  current  deflected 
into  the  coil.  This  fact  has  led  to  the  construction  of  an  instrument, 
called  "  the  galvanometer,"  for  the  purpose  of  measuring  the  strength  and 
direction  of  a  current  deflected  into  a  coil  beneath  such  a  needle.  When 
this  instrument  (properly  made  and  calibrated)  is  connected  with  a  bat- 
tery, the  strength  of  current  generated  by  any  number  of  cells  can  be 
determined  in  milliamperes.*  It  is  vitally  important  that  the  dial  of  a 
horizontal  galvanometer  should  not  be  divided  into  degrees  of  equal  dis- 
tances. Such  a  galvanometer  is  absolutely  worthless.  The  graduation 
of  the  dial  should  be  b>j  tangents^  as  shown  on  Fig.  150. 

The  deflection  of  the  needle  grows  less  and  less  for  every  milliampere 
of  current;  hence  a  dial,  to  be  accurate,  should  be  carefully  graduated 
so  as  to  correspond  with  the  needle-deflections  for  different  current- 
strengths.  The  first  divisions  on  either  side  of  the  zero  point  on  such 
a  dial  will  be  coarse,  but  the}"-  should  gradually  grow  finer  and  finer  till 
the  maximum  point  is  reached.  Such  a  dial  ivill  not  be  graduated  around 
its  entire  circumference^  as  the  maximum  point  will  be  reached  before  the 

*  Every  galvanometer  Bbould  measure  at  least  quarters  of  the  first  milliampere  to  be 
considered  worthy  of  indorsement. 


628  LECTURES   ON   NERVOUS   DISEASES. 

DC^  of  the  circle  on  cither  side  nre  re(iiiired.  One  of  my  own  galvanom- 
eters is  graded  into  equal  degrees  on  one  lialf  of  tlie  dial,  and  on  the 
other  half  it  is  calibrated  to  milliamperes. 

Within  the  past  few  years  the  cllorts  of  Erb,  Eulenbnrg,  and  Bern- 
hard  in  Germany,  Gaiffe  in  France,  and  De  Watteville  in  England  have 
awakened  the  profession  to  the  necessity  of  accurately  measuring  the 
current-strength  employed  upon  a  patient  by  means  of  a  reliable  galva- 
nometer. To  their  views  I  lend  my  most  hearty  support.  As  well  can  1 
conceive  of  a  boiler  without  a  steam-gauge,  or  of  a  drug-store  without  a 
scale,  as  a  galvanic  battery  without  a  galvanometer,  provided  its  possessor 


Fig.  150 — A  Galvanometer  Dial.  (After  De  Watteville.)  The  lower  halfof  the  circle  is  grad- 
uated to  milliamperes;  the  upper  half  to  degrees  of  equal  distance.  One  serious  criticism  can 
be  made  of  this  dial,  viz. ,  that  it  does  not  indicate  fractions  of  the  first  milliampere  of  cur- 
rent. I'o  my  mind,  a  galvanometer-needle  deflection  for  the  first  milliampere  of  current 
should  be  sufficient  to  show  at  least  a  quarter  or  an  eighth  of  a  milliampere.  This  fault  is 
common  to  all  vertical  milliampere-meters  with  which  I  am  acquainted.  Even  Hirschmann's 
instrument  does  not  entirely  overcome  it,  1  am  at  work  at  present  upon  a  new  form  of  mil- 
liampere-meter,  which  I  hope  will  remedy  this  serious  objection  and  at  the  same  time  allow 
the  needle  deflections  to  be  read  easily  when  the  eye  is  on  the  same  level  as  the  needle. 

aims  at  scientific  precision  in  his  treatment  of  patients  by  galvanism. 
Much  of  the  neurological  literature  we  now  possess  is  materially  lessened 
in  value  by  the  fact  that  the  observations  recorded  lack  scientific  precision. 
If  we  expect  to  arrive  at  })ositive  conclusions  regarding  methods  of  em- 
ploying electricity  for  therapeutic  or  diagnostic  purposes,  we  must  have 
a  more  accurate  and  scientific  basis  for  recording  the  strength  of  the 
current  employed  than  the  simple  statement  of  an  observer  "  that  a 
certain  number  of  cells  were  used  "  in  each  particular  instance.  Cells 
vary  in  their  capacity  and  electro-motive  force ;  they  change  in  both 
respects  from  day  to  day,  from  use  and  polarization  ;  tlie  external  resist- 


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629 


ance  allbrdocl  b}^  different  individuals  is  not  uniform,  altliougii  the  [toles 
miiy  be  similarly  placed  and  all  precautions  taken  against  i)oor  conduc- 
tion ;    and    many  other    sources  of  error  maj^  creep   into   observations 


"equal  parts 


Fig.  151. — A  Diagram  hesignkd  to  Illustkate  the  Method  of  Tangent  Calibration. 
— The  distances  marked  upon  the  straight  hne  are  uniform.  When  they  are  joined  by  iin-  ■ 
aginary  lines  with  the  centre  of  the  circular  dial,  these  lines  intersect  its  circumference  at 
points  which  steadily  tend  to  approach  each  other;  hence  the  first  milliampere  will  produce 
a  needle  deflection  which  may  exceed  that  produced  by  ten  or  more  milliamperes  in  some 
other  part  of  the  dial.  The  more  sensitive  the  needle,  the  greater  will  be  the  distances 
marked  upon  the  straight  line,  and  the  dial  also,  on  either  side  of  the  zero  point ;  hence  a  very 
sensitive  needle,  balanced  so  as  to  avoid  imnecessary  I'riciion,  will  record  eighths  and  quar- 
ters of  one  milliampere  of  current,  if  the  coil  be  long  enough. 

practically  made  by  "  guesswork  "  only.  The  scientific  world  has  now 
quite  generally  accepted  the  ''  milliampere  "  as  the  recognized  standard 
of  a  unit  of  current-strength. 


Fig.  152.— A  Horizontal  Milliampere-meter.  (After  the  Thistleton  pattern.)  The  screw- 
feet  allow  of  .adjustment  so  as  to  insure  a  perfect  leveling  of  the  instrument.  It  is  then 
revolved  so  that  the  needle  (which  will  point  north)  rests  at  the  zero  point  of  the  dial.  Re- 
versal of  the  current  diverts  the  needle  to  the  opposite  side  One  of  the  rheophoies  shown 
goes  to  a  binding-post  of  the  battery,  and  the  other  to  one  of  the  electrodes  employed  upon 
the  patient.  This  instrument  is  very  delicate,  but  the  eye  has  to  look  down  upon  the  dial  in 
orderto  observe  the  deflection  of  the  needle.  If  the  instrument  is  placed  lower  than  the  eye, 
this  objection  is  not  serious.  With  it  it  is  easy  to  detect  small  fractions  of  a  milliampere  of 
current,  and  it  is  miirh  less  expensive  than  a  good  vertical  galvanometer  and  more  accurate 
than  most  of  those  offered  to  the  profession.  I  do  not  recommend  them  for  measuring  very 
high  currents. 


A  milliampere-meter  is  therefore  the  ii^strtiment  which  medical 
practitioners  should  oinu  and  all  observations  should  be  recorded  from 
the  deflections  of  its  needle. 


630 


LECTURES  OX  XERYOUS  DISEASES. 


We  shall  proba])ly  be  able  soon  to  state  with  some  positiveness  the 
iininbcr  of  milliampc'res  which  are  required  to  excite  each  of  the  more 
important  nerves  of  the  human  body  in  health,  and  the  exact  limits 
between  which  contractions  of  certain  muscles  may  thus  be  excited. 
Eulenburg  and  Weiss  have  already  made  a  step  in  this  direction. 

One  reason  why  the  vertical  form  of  galvanometer  is  commonly  pre- 
ferred to  the  horizontal  is  the  fact  that  terrestrial  magnetism  does  not 


Fig.  153. — "De.\d-beat"  Mill:ampere-meter. 

exert  an  appreciable  influence  upon  it;  hence  observations  made  witli 
such  an  instrument  would  be  alike  in  all  parts  of  the  globe.  Tlie  vertical 
galvanometer  is,  however,  more  expensive,  provided  it  is  accurateh'  cali- 
brated, than  the  horizontal,  and  the  bearings  upon  which  of  necessity 
the  needle  rests  are  liable  to  cause  more  or  less  friction.  At  my  request, 
Messrs.  Waite  &  Bartlett,  of  New  York  Cit}',  have  lately  graduated 
some  horizontal  milliampei-e-meters  with  great  accurac}-  (Fig.  162).      I 


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C31 


ean  recommend  them  as  reliable  and  comparatively  inexpensive.  They 
will  not,  however,  accurately  measure  currents  of  over  titty  milliamperes. 
Before  3'ou  purchase  this  important  attachment  to  a  battery,  test  it,  if 
possible,  by  one  whose  accuracy  can  be  relied  upon.  I  would  far  rather 
have  none  than  a  poor  one.  At  i)resent  I  am  using  the  so-called  "dead- 
Ijeat "  milliampere-meter,  made  after  a  late  design.*  Hirschmann's 
vertical  galvanometer  with  astatic  needles,  called  the  "  absolute  galva- 
nometer," has  been  highly  recommended  of  late.  I  have  not  yet  pur- 
chased one,  as  I  lind  my  own  to  be  perfectly  reliable. 

The  instrument  represented  on  opposite  page  measures  from  one- 
tenth  of  one  milliampere  to  five  hun- 
dred milliamperes.  It  is  contained  in 
an  all-metal  case  and  carefully  cali- 
brated. It  contains  the  Siemens'  bell- 
magnet,  and  is  dampened  in  its  vibra- 
tions by  the  induced  currents  set  up 
during  the  deflections  of  the  needle, 
Avhereas  in  most  instruments  of  the 
better  class  the  oscillations  of  the 
needle  average  at  least  twenty-five 
before  it  comes  to  rest.  In  this  in- 
strument the  vibrations  seldom  ex- 
ceed from  five  to  six.  Shunts  are  pro- 
vided in  order  to  measure  very  high 
currents.  I  regard  this  instrument 
as  fully  equal,  if  not  superior,  to 
Hirschmann's  expensive  instrument. 

The  Eheostat.  —  This  is  an 
appliance  to  regulate  the  external 
resistance  of  a  battery  under  varying 
circumstances.  Several  devices  are 
made  for  this  purpose,  but  the  fluid 
rheostat  (containing  water,  solutions 

of  salt,  solutions  of  zinc  sulphate,  etc.)  is  often  all  that  is  required 
for  medical  uses.  It  is  cheap,  easily  managed,  and  modifies  the  current- 
strength.  It  is  liable  to  polarize  f  Avhen  used  too  long,  and  does  not  act 
so  well  with  strong  curi-ents  as  with  weak  ones.  It  consists  of  a  glass 
tube  filled  with  water  or  some  prepnred  solution  (preferably  a  forty  per 
cent,  solution  of   sulphate  of  zinc),  through  which  a  brass  rod  or  an 


Fig  I'A. — A  Fluid  Rheostat. — This  instrument 
is  used  to  throw  additional  external  resistance 
into  circuit.  Coil  rheostats  are  more  reliable, 
because  fluid  is  decomposed  and  causes  polari- 
zation of  the  metal  points  when  strong  currents 
are  used.  Some  of  the  graphite  rheostats  are 
preferable  to  many  containing  fluid,  and  are 
cheaply  made. 


*  This  is  shown  in  a  cut  of  my  own  cabinet  battery,  on  a  succeeding  page,  and  in 
Fig.  1.53. 

t  We  speak  of  an  element  as  " polari?.cd^'  when  bubbles  of  hydrogen  or  oxygen  accu- 
mulate upon  it,  and  thus  diminish  its  efficiency. 


632 


LECTURES   ON   NERVOUS   DISEASES. 


amalgamated  zinc  electrode  is  made  to  slide  \\\)  and  down,  thus  separating 
its  lower  end  from  a  button  at  the  bottom  of  the  tube.  When  the  cur- 
rent is  sent  through  this  rod,  it  is  forced  to  pass  through  the  depth  of 
fluid  that  lies  below  it  in  order  to  reach  the  button  at  the  bottom  of  the 
tube.  By  moving  this  rod,  the  amount  of  fluid  which  is  thus  interposed 
in  the  circuit  of  the  battery  can  be  graduated  to  any  desired  point.  In 
this  way  a  greater  or  less  resistance  can  be  made  at  will.    A  fluid  rheostat 

is  absolutely  useless  for  measuring  the 
strength  of  a  current,  but  is  an  excellent 
appliance  for  modifying  it. 

A  new  fluid  rheostat  has  lately  been 
devised  b}'  II.  li.  Bailey,  which  has  been 
highly  recommended  by  Rosebrugh,of 
Canada,  and  others.  I  have  had  no  per- 
sonal experience  with  this  instrument. 
It  certainl}'  does  not  measure  resistance 
(as  a  Avell-constructed  coil  rheostat  may 
be  made  to  do),  but  it  may  prove  a 
valuable  adjunct  to  an  electrical  outfit 
for  practical  purposes.  Fig.  155  shows 
the  instrument  referred  to. 

The  carbon  plates  of  this  device 
are  made  of  a  wedge  shape,  and  have 
pyramidal  pieces  of  sponge  placed 
between  them.  As  the  plates  are  with- 
drawn from  the  fluid  in  the  jar  these 
sponges  hold  sufficient  water  to  aftbrd 
an  extremely  high  resistance  to  the  pas- 
sage of  the  current.  When  the  plates  are 
fully  immersed  the  resistance  attbrded 
is  extremely  small.  It  is  claimed  that 
from  ten  to  one  million  ohms  of  resist- 
ance can  be  thrown  into  the  circuit 
with  this  instrument.  It  is  further 
claimed  that  by  raising  or  lowering  the 
plates  of  this  rheostat  tlic  necessity  of  n 
commutator  is  dispensed  with,  even  for  the  purpose  of  preventing  a 
shock  to  the  patient  when  the  i)oles  are  applied  or  removed. 

.  The  TuERMo-ELKCTUTf  PiFrKKENTiAL  Calorimeteu. — Tliis  apparatus 
is  used  in  medicine  to  measure  ditlerences  in  tempev.ature  in  homologous 
parts  of  the  body,  or  of  any  two  selected  points.  It  is  much  more  deli- 
cate than  any  form  of  surface  thermometer,  and  is  often  very  valuable  as 
an  aid  in  making  a  scientific  diagnosis.     Like  many  of  the  instruments 


Fi'i    lu"). — Rosi-.iiKi(;ns    Kluio    Rhfostat 
( Ciinaiia  Pract. ) 


ATTACHMENTS   TO   A   COMPLETE   BATTEKY. 


633 


of  precision,  it  requires  experience  to  use  it  and  it  is  somewhat  expensive. 

The    study  of   surface    thermometry   has  not    assumed    the    importance 

which,  in  the   opinion  of  the 

author,  it   is  destined   yet   to 

take.      Waite    &    Bartlett,   of 

New   York,  have   constructed 

for  me  one  of  the  most  perfect 

instruments  of  tliis  kind  that  I 

have  ever  seen. 

The  study  of  ccrel)ral  ther- 
mometry has  already  led  to  the 
discovery  that  the  left  hemi- 
sphere is  normally  hotter  than 
the  right  (Hammond) ;  that 
willed  muscular  action  raises 
the  temperature  of  the  scalp 
over  the  motor  centres  called 
into  action  (Amidon,  Gray, 
and  others);  that  mental  ac- 
tivity, emotional  excitement, 
and  merely  arousing  the  atten- 
tion cause  a  rise  in  temperature 
( Lombard) ;  and  that  tumors 
of  the  brain  or  its  envelopes 
are  indicated  by  a  localized 
rise  in  temperature  over  the 
Ksite  of  the  neoplasm.  I  have 
lately  made  some  novel  and 
interesting  experiments  in  this 
field  which  I  propose  shorth' 
to  i)nblish.  In  detecting  in- 
Hammatory  conditions  of  the 
abdominal  viscera,  this  instrument  has  lately  been  emi^loyed  with 
satisfactory  results.     I   have  lately  made  an  inii)rovement  *  upon  this 

*The  improvement  to  which  I  refer  consists  in  tlie  addition  of  a  polarity  changer  of 
my  own  construction,  which  enables  me  to  reverse  the  deflection  of  the  needle  without 
removing  the  thermo-piles  from  the  surface  of  the  patient.  If  the  needle,  for  example, 
sfiows  a  deflection  of  1.5°  when  <me  thermo-pile  is  on  the  right  side  and  12°  on  the  left 
side,  the  difference  of  1)°  shows  double  the  imperfection  which  exists  in  the  thermo-pilc 
thus  tested,  and  the  proper  registration  should  therefore  be  IS'^o.  Such  imperfections 
in  thermo-electric  piles  are  practically  unavoidable  and  can  be  detected  in  no  other 
way.  As  far  as  I  l^now,  this  defect  has  never  before  been  remedied.  This  has  here- 
tofore been  the  only  serious  drawback  to  the  differential  calorimeter,  and  the  addition 
of  this  improvement  renders  the  instrument  far  more  valuable  for  accurate  scientific 
purposes. 


Fig.  156. — Thermo-Electkic  Differential  Calori- 
meter.— Connect  the  two  thermostats  as  shown  in  figure, 
viz.  :  connect  by  means  of  one  of  the  metal-tipped  cords 
one  binding-post  of  each  of  the  thermo-piles  to  the  two 
binding-posts  on  base  of  the  galvanometer,  'then  con- 
rect  the  two  remaining  posts,  one  on  each  of  the  thermo- 
piles with  each  other.  After  so  doing,  place  the  thumb 
on  the  face  of  one  of  the  theimo-iiiles  and  observe  the 
direction  of  the  deflection  of  the  galvanometer-needle, 
then  place  thumb  on  face  of  the  other  thermo-pile,  leaving 
the  first  uncovered,  and,  if  the  deflection  is  in  the  oppo- 
site direction  to  that  first  obtained,  the  instruments  are 
properly  connected.  If,  however,  the  second  deflection 
is  in  same  direction  as  obtained  by  pressing  thumb  on 
first  thermo-pile,  disconnect  the  two  cords  from  either 
thermo-pile  and  interchange  them,  viz.  :  take  cord  from 
right-hand  post  and  place  in  left,  and  cord  from  left  post 
and  place  in  right-hand  post;  the  defleciions  will  then 
be  as  first  alluded  to,  one  pile  turning  needle  in  one  direc- 
tion and  the  other  in  the  opposite  direction. 


634 


LECTURES   ON   NERVOUS   DISEASES. 


instrument  which  enables  the  physician  to  detect  differences  in  the 
electro-motive  force  of  the  thornio-eloctric  piles  employed.  This  corrects 
all  errors  in  observations  made  with  this  instrument. 

The  Current-Selector. — This  device  is  now  added  to  all  of  the 
modern  galvanic  batteries,  whether  designed  for  ofllce  use  or  for  trans- 
portation. By  it,  the  number  of  cells  desired  can  be  thrown  into  circuit. 
If  a  circular  dial  studded  with  buttons  (which  represent  the  cell-connec- 
tions) is  used,  the  bar  which  reA'olves  and  impinges  upon  the  buttons 
acts  as  a  connection  between  the  button  on  which  it  rests  and  the  metallic 
pivot  on  which  it  revolves. 


Fig.  157. — A  New  Form  of  Current  Selector. — This  allows  ni  :i  sel.  rn-m  of  any  desired 
number  of  cells  from  any  part  of  the  battery,  thus  insuring  equal  wear  and  many  other 
advantages. 

It  is  important  that  this  bar  be  broad  enough  to  touch  each  button 
before  it  leaves  the  one  behind  it,  otherwise  the  current  is  apt  to  be 
In-oken  when  the  intensity  of  the  current  is  changed.  I  have  known  of 
serious  results  from  such  an  accident  when  a  large  number  of  elements 
were  being  used  upon  the  head  of  a  patient.  At  my  suggestion,  a  modi- 
fication of  the  dial  current-selector  has  been  made  by  Waite  &  Bartlett, 
of  NeAv  York  City  (Fig.  157). 

Another  form  of  current-selector  is  that  employed  by  the  same  firm 
for  some  of  their  instruments.  I  greatly  prefer  it  to  any  other  kind  for 
a  portable  battery,  as  it  enables  the  operator  to  select  the  desired  number 
of  cells  from  any  part  of  the  battery,  thus  insuring  an  equal  amount 


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635 


of  wear  upon  all  of  its  parts.  It  consists  of  pins  projecting  from  the 
(Hal-plate,  each  of  which  represents  one  cell.  These  may  be  brought 
into  circuit  by  means  of  two  metal  caps,  which  are  placed  upon  any  of 
the  pins  desired  ;  the  number  of  pins  between  the  caps  will  immediately 
tell  the  operator  how  many  cells  are  being  used.     An  objection  to  its 


-'R 


Fig.  158.— a  Skeleton  Drawing  op  the  Pin  Variety  of  Portable  Galvanic  Battery. 
/v ,  handles  by  which  the  tray  of  cells  is  raised  and  lowered.  Z.  zinc  elements.  C,  caibon 
elements.  ^,  5,  binding-posts.  /),  attachment  of  the  stopper  which  fits  over  the  pins,  /f, 
a  rubber-covered  diaphragm  which  separates  the  cells  from  the  elements  when  the  battery  is 
not  in  use;  this  is  removed  when  the  cells  are  lifted  so  as  to  immerse  the  elements. 


use   is  that  it  dispenses  with  a   polarity  changer,  —  in  case  the  cells 
employed  are  capable  of  being  thus  selected. 

Fig.  158  shows  a  portable  galvanic  battery  of  this  make  with  the 
current-selector  attachment  described.  In  this  form  one  stopper  only  is 
employed,  however,  and  the  cells  in  use  are  indicated  by  tlie  numerals 
placed  at  the  base  of  each  pin.    With  this  arrangement  a  polarit}^  changer 


G36  LECTURES   ON   NERVOUS   DISEASES. 

is  admissibk',  and  is  irencrally  allixed  to  all  so  constructed.  This  is 
particular!}'  to  be  desired. 

One  claim  that  is  made  iu  favor  of  this  device  is  that  this  form  of 
key-board  prevents  oxidation,  as  the  wires  which  are  usually  emplo>-ed 
to  join  the  cell-elements  with  the  current-selector  in  other  apparatuses 
are  entirely  dispensed  with.  This  advantage  is  an  important  one  to 
those  who  live  away  from  the  large  cities  and  are  not  sufficiently  familiar 
with  electrical  apparatus  to  make  their  own  repairs.  Furthermore,  the 
employment  of  the  metal  cap  keeps  the  metal  pins  free  from  rust,  and 
gives  a  perfect  metallic  contact  because  the  pins  are  being  constantly 
kept  bright  and  clean. 

In  batteries  which  are  formed  of  a  large  number  of  cells,  it  is  best 
to  have  two  dial  current-selectors,  so  that  a  gradual  increase  or  decrease 
of  the  current  can  be  made  without  breaking  the  circuit.  In  one  dial 
each  button  should  represent  one  cell,  while  in  the  other  each  should 
represent  from  two  to  five  cells..  -It  is  easier  to  make  any  desired  com- 
bination of  cells  with  rapidity  by  means  of  such  an  arrangement  than  if 
the  dials  were  alike. 

TfiE  Polarity  Changer  or  Commutator. — Most  galvanic  batteries 
have  a  switch  upon  the  key-board  that  is  intended  for  the  purpose  of 
changing  the  poles  at  will  without  disturbing  the  rheophores  or  elec- 
trodes. The  details  of  the  man}-  mechanical  contrivances  emplo3'ed  for 
tliat  purpose  need  not  be  given  here. 

This  attachment  is  almost  indispensable  to  a  battery  designed  for 
oflfice  or  experimental  work,  since  the  reactions  of  the  poles  can  thus  be 
more  readily  studied.  It  is  desirable,  moreover,  to  have  it  attached  to  a 
portable  galvanic  batter}-. 

It  should  be  so  arranged  as  to  permit  of  ojyening  and  closure  of  the 
circuit,  as  well  as  the  reversal  of  the  curi^ent. 

The  Rheophores. — These  are  flexible  wires  which  are  necessary  to 
conduct  the  electric  current  from  the  battery  when  in  action  to  the 
patient.  Insulated  cop])er  wire  forms  the  best  rheophore,  as  it  is  an 
admirable  conductor.  Tinsel  threads  insulated  with  cotton  wrapping  are 
more  generally  used,  because  they  do  not  kink  and  are  more  flexible 
(although  they  ai-e  not  such  good  conductors).  They  are  connected  at 
one  end  to  the  "  binding-jyo-^ts  "  of  the  battery,  and  at  the  other  to  the 
electrode.  They  should  vary  between  four  and  six  feet  in  length.  I 
have  some  that  are  ten  feet  in  length,  which  I  employ  when  I  examine 
the  naked  body  of  a  patient  lying  upon  a  sofa  or  bed. 

The  Electrode. — In  order  to  apply  a  current  of  electricity  generated 
iu  a  battery  to  the  human  body,  various  forms  of  electrodes  are  employed 
as  termini  to  the  rheophores.  It  is  best  to  have  a  pair  of  handles  to 
which  different  forms  of  tips  ma}-  be  screwed,  according  to  the  require- 


ATTACHMENTS   TO   A   COMPLETE   BATTERY. 


637 


ments  of  each  case.  The  tips  may  be  made  of  plain  metal,  or  of  carbon 
or  metal  covered  with  sponge,  chamois-skin,  or  canton-flannel.  The 
canton-flannel  covering  is  the  chea{)est  and  cleanest,  and  may  be  renewed 
at  pleasnre.  Each  patient  can  thns  have  a  clean  covering  for  the  elec- 
trode at  every  application.  Flat  electrodes  of  large  size  are  iisefnl, 
especialljr  when  a  nentral  point  for  the  cnrrent  is  desired.  Small  tips 
(motor-point  electrodes)  are  generallj-  employed  to  direct  the  current  to 
some  special  muscle  or  group  of  muscles. 


Fig.  159.— Various  Forms  of  Electrodes  (Natural  Size),  adapteuto  a  Screw  Handle, 
NOT  SHOWN  IN  THE  CUT.  (After  Erb. )  a,  the  "fine"  electrode,  or  smallest  size;  d,  the 
so-called  "small"  electrode;  c,  the  "  medium"  electrode.  All  electrodes  are  covered  with 
sponge   (as  in  a  and  6)  or  flannel  or  chamois-skin  (as  in  c). 

The  wure  brush  is  emploj^ed  chiefly  in  cases  where  anaesthesia  exists. 
It  is  the  only  electrode  that  is  used  dry. 

Most  manufacturers  advertise  a  case  of  electrodes  designed  especi- 
ally for  the  application  of  electricity  to  diflferent  organs.  Selections  may 
be  made  from  these  as  desired.  I  have  personally  devised  several  modi* 
fications  of  electrodes. 


638 


LECTURES    OX   NERVOUS   DISEASES. 


A  practical  point  ma}-  he  mentioned  here,  viz.,  that  the  negative 
electrode  (cathode)  is  tlie  most  painful  to  the  patient,  and  produces  the 
greatest  cliemical  action.  It  is  a  well-recognized  fact  that  a  bullet  does 
the  most  damage  at  its  point  of  escape  from  any  dense  substance  whicli 
it  has  penetrated.     In  the  same  way  an  electric  current  produces  the 


Intra-uterine. 


Ulcer  Plate. 


bpu"riS  Electrode. 


Aural. 


Double-current   K^M.-.r 
Fig.  160. — Various  Forms  of  Special  Electrodes. 

most  profound  effects  at  its  point  of  escape  from  the  bod}",  i.e.,  the 
negative  pole.  It  is  not  uncommon  to  see  a  reddening  of  the  skin,  and 
even  vesication,  produced  by  a  strong  current  at  the  negative  electrode, 
if  kept  too  long  in  contact  with  it.  The  cathode  is  the  "  stimulating  " 
or  "  irritating  "  pole  (if  such  an  exjjression  is  admissible)  of  a  galvanic 
batter}^     The  anode  is,  b}-  contrast,  the  "  sedative  "  pole. 


CHOICE  OF  A  BATTEEY  AND  ELECTKICAL  APPARATUS.    639 

For  the  treatment  of  special  forms  of  disease  by  electricity,  different 
types  of  electrodes  have  been  designed  by  various  neurologists.  A  de- 
vice of  my  own,  which  simplifies  electro-diagnosis  and  enables  a  medical 
observer  to  watch  and  compare  the  effects  of  electrical  currents  of  defi- 
nite strengths  upon  muscle-  and  nerve-reactions  of  opposed  limbs  simul- 
taneously, has  been  described  in  Section  II.  By  means  of  this  device, 
tlie  physician  may  sit  at  a  key-board  and  excite  different  sets  of  muscles 
separately  or  simultaneously  (without  moving  from  his  chair)  by 
touching  certain  ke3^s,  as  if  playing  the  piano  or  working  a  tj'pe-writer. 
I  have  found  it,  moreover,  of  great  assistance  in  demonstrating  before 
large  audiences  the  action  of  nerves  and  muscles  upon  a  living  sul)ject. 

Space  will  not  allow  of  a  detailed  description  of  the  electrodes  shown, 
most  of  them  being  simple  devices,  which  really  require  but  a  limited 
experience  to  use  them  in  a  proper  way. 

When  3'ou  purchase  a  batter}-,  two  sponge-covered  electrodes  will 
probably  be  sent  with  the  instrument.  It  is  advisable,  for  the  following- 
reasons,  to  remove  the  sponges  :  (1)  Cases  have  been  reported  where 
disease  has  been  transmitted  by  sponge-covered  electrodes.  (2)  In  case 
the  metal  electrodes  become  oxidized,  they  can  be  readily  cleaned.  (3) 
When  emploved  upon  a  patient's  body,  absorbent  cotton,  wet  in  salt 
water,  can  be  placed  upon  the  clean  metal,  and  a  piece  of  moistened 
canton-flannel  may  then  be  wrapped  over  both  and  fastened  to  the  handle 
with  a  rubber  band,  thus  insuring  absolute  cleanliness  and  perfect  conduc- 
tion of  the  electric  current. 

Patients  of  delicate  sensibilities  rebel  against  the  nse  of  sponges 
which  for  months  or  even  years  have  been  emplo3ed  in  case  after  case 
requiring  electricit}'.  Who  would  patronize  a  barber-shop  where  one 
towel  constituted  the  entire  outfit  of  linen?  Is  it  right  to  ask  of 
patients  what  3'ou  would  yourself  condemn?  Furthermore,  how  can 
electrodes  covered  with  dirt  and  other  deposits  under  a  sponge  be  perfect 
conductoi's  of  electricity-  ?  Absorbent  cotton  and  canton-flannel  are  far 
cheaper  than  sponges,  and  can  be  thrown  away  after  being  used. 

THE  CHOICE  OF  A  BATTEKY  AND  ELECTEICAL  APPAKATUS. 

In  selecting  a  battery  for  purely'  medical  purposes,  the  chief  objects 
to  be  attained  are,  to  my  mind:  (1)  cZ/ea^jnessy  (2)  constancy  of  the 
elements  and  their  accessibility  for  repairs,  cleaning,  etc.;  (3)  durability 
of  the  elements ;  (4)  a  sufficient  number  of  elements;  (5)  ease  of  reneival 
of  the  elements;  (6)  ease  of  introduction  of  any  number  of  elements  into 
the  circuit;  and  (7)  an  ability-  to  select  such  as  may  be  required  from 
any  part  of  the  battery. 

For  the  general  practitioner  it  is  necessaiy,  as  a  rule,  that  a  gah-anic 
or  faradaic  battery-  shall  be  arranged  for  transportation;  hence  the  cups 


640 


LECTURES   ON   NERVOUS  DISEASES. 


wliich  hold  the  fluid  should  have  a  rubber  cover,  or  some  other  device 
wliich  will  preclude  the  possibility  of  spilling  the  fluid.  Again,  some  of 
tlie  butteries  manulactured  are  liable  to  become  rapidly  oxidized  by  the 
fumes  of  the  battery-fluid.  This  tends  to  destroy  their  durability,  and 
to  cause  ditliculty  in  keeping  them  in  good  working-order.     Finally,  it  is 


V^V'AC 


Fig.  161. — The  Physician's  H.andv Cabinet  Battery.  (Author' s model.)  Theaccompany- 
iiig  cut  represeiiis  a  light  and  compact  form  of  cabinet  battery,  designed  by  the  author.  It 
is  on  castors,  and  can  be  wheeled  about  the  consuhation-room.  This  admits  of  the  useof  the 
instrument  when  the  patient  is  in  the  gyna;cological  chair  or  upon  the  office  lounge;  or  when 
any  form  of  fi.xeJ  apparatus,  such  as  the  laryngoscope,  the  inhaler  or  spray,  etc.,  is  being 
simultaneously  employed.  In  some  of  my  later  models  an  immovable  tray  is  placed 
beneath  the  battery  for  electrodes,  and  a  movable  shelf  is  also  provided  upon  which  a  mil- 
liampere-meter,  the  solution  of  table  salt,  and  the  electrodes  in  actual  use  can  beset.  A  glass 
cover  protects  the  battery  from  dirt  when  not  in  use.  .£',  far.adaic  coils;  A',  plunger;  O, 
faradaic  binding-posts:  7^,  interrupter;  />,  drip-cup:  A",  current-selector  of  single  cells; 
5,  the  same  of  four  cells  to  each  button;  71/,  coil  to  work  the  interrupter  lor  the  galvanic 
current ;  L,  switch  to  work  or  disconnect  the  interrupter  (  ?  ) ;  /',  galvanic  binding-posts; 
3-5  and  4-6,  connecting  rods  to  allow  of  the  action  of  M.     The  commutator  lies  above  P. 


very  desirable  that  portable  batteries  should  be  as  light  as  possible,  and 
not  too  large  to  be  handled  easih'. 

The  attachments  upon  the  key-hnai^d  of  every  portable  galvanic  bat- 
tery should  comprise  a  current-selector  and  a  commutator.  There  should 
be  at  least  four  rheophores,  in  order  to  make  allowance  for  breakage, 


CHOICE  OF  A  BATTERY  AND  ELECTRICAL  APPAEATUS.    641 

julditional  eoniicctions,  etc.  Several  electrodes  of  different  sizes  and 
shapes  should  also  be  selected, — preferably  a  large,  a  medium,  and  a  small 
one, — a  wire  brush,  and  an  interrupting  electrode.  These  can  be  added 
to  as  circumstances  demand. 

For  olHce  purposes,  a  cabinet  battery  has  some  decided  advantages 
over  a  permanent  one  placed  in  an  adjoining  closet  or  cellar  and  con- 
nected, by  means  of  wires,  with  a  key-board  in  the  consulting-room.  A 
cabinet  battery  can  be  easily  wheeled  about,  and  is  readily  repaired. 
The  cabinet  should  be  so  arranged  as  to  allow  the  back  and  front  of  the 
compartment  for  the  cells  to  be  removed,  in  case  the  batter}^  needs 
repairs  or  a  renewal  of  the  fluid.  The  connections  of  the  battery  with 
the  key-board  should  also  be  made  as  easy  of  access  as  possible ;  this 
decreases  the  expense  of  alterations  or  repairs  when  such  becomes 
necessary.  They  should  be  protected,  moreover,  as  far  as  possible, 
against  oxidation  and  dirt. 

The  cabinet  battery  which  I  use  in  my  own  office  was  made,  under 
my  special  direction,  b}^  Waite  &  Bartlett,  of  New  York  City,  and  is  as 
nearly  perfect  as  one  could  desire.  It  contains  forty  cells  of  the  Le- 
elanche  jjattern,  which  are  equivalent  to  sixty  of  the  gravit}'  cell.  The 
connections  and  the  cells  can  be  exposed  and  easil}'  reached  by  removing 
the  front  and  back  of  the  case.  The  cut  on  the  following  page  represents 
its  special  features  better  than  a  long  description.  Considerable  expense 
in  constructing  such  a  battery  may  be  saved  in  the  case,  and  by  dis- 
pensing with  some  of  the  accessory  apparatus  shown. 

The  perfected  office  cabinet  battery  (Fig.  162)  was  made  after 
my  own  designs.  It  consists  of  a  handsome  cabinet,  arranged  for 
storing  the  cells  in  the  under  part  as  shown.  The  upper  part  consists 
of  a  shallow  closet  suitable  for  affixing  the  n})right  switch-l)oard  as 
shown.  The  closet  contains  forty  cells  of  the  kind  generally  known  as 
the  "  Gonda-Leclanche,"  for  use  as  the  galvanic  part  of  the  apparatus, 
and  four  extra  cells  to  be  used  in  running  the  faradaic  part  of  the 
apparatus.  The  switch-board  is  provided  with  a  universal  current-selector 
for  the  galvanic  part  of  the  apparatus,  by  means  of  which  any  cell  or 
series  of  cells  can  be  brought  into  the  circuit;  thus  doing  away  with  the 
necessity  of  using  cells  from  the  same  part  of  the  group,  in  order  that 
the  cells  can  be  worked  and  used  up  evenly.  It  is  also  proAided  (1)  with 
an  attachment  for  interrupting  the  galvanic  current ;  (2)  a  wire  rheostat, 
for  interposing  resistance  into  the  circuit;  (3)  a  pole-changing  attach- 
ment ;  and  (4)  a  milliampere-meter  for  measuring  the  current-flow  during 
treatment.  By  means  of  a  milliampere-meter  and  the  wire  rheostat,  the 
resistance  afforded  by  the  patient  at  the  time  of  the  sitting  may  be  readily 
measured.  The  apparatus  also  has  a  complete  faradaic  attachment ;  this 
latter  being  provided  with  fast  and  slow  contact-breakers,  as  well  as  a 

41 


642 


LECTURES   ON   NERVOUS   DISEASES. 


Fig.  ]G'2 — The  Perfecteu  Ofpicf  Cabinet  li.\TiEKY.     (Aut/iors  t>:oi{ei.) 


CHOICE   OF   A   BATTERY   AND   ELECTllICAL   APrARATUS.         643 

contact-key  to  be  worked  by  pressure  of  the  finger  jit  the  will  of  tlie 
operator.  This  latter  attachment  is  of  special  use  in  electro-diagnosis. 
The  cabinet  is  mounted  on  rubber-tired  castors  of  large  diameter,  and  can 
readil}^  be  moved  on  finished  and  polished  floors  without  marring  the 
same.  It  is  also  provided  with  a  large  drawer  and  closets  for  the  elec- 
trodes. The  milliampere-meter  attached  to  this  cabinet  is  separately 
shown  in  Fig.  153. 

I  believe  this  cabinet  to  be  the  most  complete  for  practical  work  in 
electro-diagnosis  and  general  electro-therapeutics  that  has  ever  been 
ottered  to  the  profession.  [I  am  having  a  new  cabinet  so  arranged  for 
m}'  own  nso  as  to  contain  a  storage  battery,  so  that  I  can  emplo3-  the 
electric  lamp  or  cautery  at  will.  This  is  charged  as  circumstances 
require.  It  can  be  removed  from  the  cabinet  and  transported  for 
examinations  or  treatment  at  the  patient's  residence.] 

A  PERMANENT  BATTERY  is  somcwhat  cheaper  to  construct  and  takes 
up  less  room  in  the  office  than  a  cabinet,  because  no  case  is  required  ; 
but,  in  my  opinion,  these  two  advantages  are  not  sufficient  to  render  it 
preferable  to  the  other  for  office  or  experimental  work.  I  have  known 
several  of  m}"  medical  friends  to  discard  it  (after  a  thorough  trial)  for 
a  cabinet  battery.  If  a  permanent  battery  is  deemed  preferable  by  any 
of  you  (for  reasons  of  your  own)  rather  than  a  cabinet  battery,  be  sure 
and  place  your  cells  on  shelves  in  3'our  office  or  waiting-room,  and  not 
in  a  cellar.  The  wires  will  not  be  so  liable  to  corrode  from  dampness, 
and  the  cells  will  be  constantly  under  your  eye,  so  that  j^ou  can  see  when 
they  require  attention. 

The  gravity  cell  makes  a  very  serviceable  and  durable  permanent 
battery  for  office  work.  It  has  one  advantage  over  some  other  cells,  viz., 
that  it  has  great  constancy  of  action  and  that  its  activitj'  can  be  renewed 
133'  the  addition  of  crystals  of  sulphate  of  copper  to  the  fluid  when 
necessary  without  disturbing  the  cells.  For  this  reason  the  sulphate- 
of-copper  cell,  in  some  one  of  its  various  forms,  is  emplo^-ed  exclusivelv 
in  telegraphic  lines.  Unfortunately^,  it  tends  to  "  salt  "  excessively,  and 
the  jars  and  elements  become  incrusted  unless  the}- are  carefully- watched 
and  taken  care  of  Again,  it  cannot  be  transported  about  the  room  to 
suit  the  convenience  of  the  patient  or  the  physician  during  his  examina- 
tion so  well  as  some  other  cells  adapted  for  a  cabinet  batterj'.  It  is  also 
difficult  in  many  cases  to  repair  the  Avire  connections  of  a  fixed  battery- 
(running,  as  tiiey  often  do,  through  partitions  and  plastered  walls  to 
reach  the  kej'-board)  when  they  become  inefficient  from  any  cause.  I 
personally  prefer  the  Leclanche  cell  to  any  other  ^x't  devised  for  a  cabinet 
battery. 

The  engraving  on  page  G44  represents  the  perfected  cabinet  so 
arranged  as  to  be  detached  from  the  cells  and  screwed  to  the  wall.     The 


644 


LECTURES  ON  NERVOUS  DISEASES. 


Fig.  163.— The  Perfectbd  VV all-Cabinf.t.     {Ant/ior's  model.) 


THE   CAEE   OF   A   BATTERY.  045 

cells  may  be  placed  in  an}^  convenient  place,  as  closet  or  cellar.  It  is 
the  same  in  all  of  its  attachments  as  the  perfected  cabinet  just  described. 

Respecting  the  selection  of  the  cheaper  forms  of  batteries  for  gen- 
eral medical  use,  it  is  important  that  accuracy  of  workmanship  shall  not 
have  been  sacrificed  in  order  to  lessen  the  cost.  The  construction  of 
the  primarj-^  and  secondary  coils  of  a  faradaic  machine  and  the  adapta- 
bility of  the  interrupter  to  slow  and  rapid  breaks  in  the  circuit  should 
be  looked  into  before  a  decision  is  reached.  Poor  coils  and  a  bad  inter- 
rupter render  a  iaradaic  machine  almost  worthless.  A  "  d7'ii>ciqD  "  con- 
taining mercury,  in  which  the  zinc  element  is  placed  when  the  battery  is 
not  in  use,  is  a  desirable  feature  in  a  faradaic  machine. 

Do  not  buy  a  magneto-electric  machine  wiiose  motor  power  is 
furnished  by  a  crank  to  be  turned  by  the  hand.  It  is  practically  useless 
for  medical  purposes  when  compared  with  a  good  ftiradaic  instrument. 

The  Grenet  cell  is  now  used  by  most  of  tlie  manufocturers  of 
electrical  apparatus  for  a  portable  galvanic  or  faradaic  battery.  It  is 
the  best  cell  for  this  purpose,  in  my  opinion,  for  many  reasons  that  I 
have  already  expressed  in  print.*  A  thirty-cell  galvanic  battery  of  this 
type  gives  all  the  current  that  is  required  by  the  general  practitioner. 

Every  galvanic  battery  should  have  a  commutator  on  the  key -board. 
Without  this  appliance  electro-diagnosis  becomes  ditlicult. 

THE   CAEE   OF   A   BATTEEY. 

The  best  battery  is  liable  to  get  out  of  order.  It  is  an  easy  matter, 
as  a  rule,  to  correct  the  trouble  if  the  construction  of  the  apparatus  is 
thoroughly  understood.  The  following  hints  may  aid  the  reader  in 
obtaining  a  satisfactory  current  Avith  a  minimum  expense : — 

1.  Keep  your  battery  clean  and  bright  in  all  its  pat^ts.  Close  the 
case  when  the  battery  is  not  in  use,  and  thus  keep  out  dust,  grease,  and 
moisture.  Emery-paper  is  useful  to  keep  the  metal  connections  free 
from  rust.  Remember  that  a  small  amount  of  dirt,  grease,  or  rust  will 
often  arrest  the  action  of  any  batter^'. 

2.  When  the  battery  fails  to  act  properly,  examine  the  cells  first  and 
see  \T  the  fluid  requires  reneival.  The  "red-acid  fluid"  is  easil}- made 
by  adding  one  part  of  commercial  sulphuric  acid  to  ten  parts  of  cold 
water;  when  cooled,  one  part  of  finel}'  pulverized  bichromate  of  potas- 
sium should  be  added  and  mixed  well.  This  is  the  fluid  commonly 
employed  in  portable  batteries  with  cells  of  the  Grenet  pattern. 

3.  If  the  fluid  is  found  to  be  fresh,  and  if  the  zinc  and  carbon 
elements  are  in  good  order  and  the  zinc  well  amalgamated,  examine  care- 
full;/  all  Ihe  screxL'S  and  other  connections  attached  to  the  elements  and  see 
if  the3'   have  become  oxidized.     Sometimes  thej^  become  rusted  or  so 

*.V.   r.  Jfed.  Journal,  1SS5. 


C46  LECTURES   ON   NERVOUS   DISEASES. 

covered  with  accumulated  dirt  as  to  render  the  passage  of  tlie  current 
impossible.  Occasionally  the  carbons  may  be  disconnected  and  baked  in 
an  oven  to  render  a  Grenet  cell  more  active.  Soaking  the  elements  (in 
ailii)  in  hot  water  which  does  not  reach  the  connections  will  generally 
suffice  to  cleanse  them. 

4.  If  the  cell  Jias  become  polarized  when  in  action  (by  bubbles  of 
hydrogen  which  accumulate  upon  the  carbon  and  of  oxygen  upon  the  zinc 
element),  lifting  the  zinc  out  of  the  fluid  and  replacing  it  immediately 
will  suffice  to  overcome  this  trouble,  whenever  the  cells  are  of  the  Grenet 
pattern.  These  bubbles  of  hydrogen  and  oxygen  set  up  a  counter- 
current  in  the  cell,  which  will  weaken  and  may  even  neutralize  the 
original  current. 

5.  Examine  the  interrupter,  the  buttons  of  the  current-selector,  and 
the  commutator  for  rust  or  dirt,  and  clean  each  thoroughh'  -svhen  the 
trouble  appears  not  to  be  due  to  the  elements  or  their  immediate  con- 
nections. 

6.  If  a  drip-cup  is  furnished  with  a  faradaic  or  galvanic  battery,  be 
careful  to  place  the  zinc  element  in  it  when  the  batter}^  is  not  in  use. 

T.  In  portable  galvanic  batteries,  be  sure  to  place  the  rubber<-overed 
diaphragm  over  the  cells  before  closing  the  case  and  to  screw  it  down 
tightly.  This  prevents  the  fumes  rising  and  oxidizing  the  connections 
of  the  elements  when  not  in  use. 

8.  Be  sure  that  the  rheophores  are  perfect  before  they  are  used  ui)on 
a  patient.  The  wire  used  in  their  manufacture  is  liable  to  become  broken 
or  oxidized  by  use.  This  is  especially  true  of  the  flexible,  cotton-covered 
cords  generally-  furnished  with  batteries.  The  electrodes  may  be  tested 
by  emplo^'ing  a  galvanometer,  if  an  imperfection  is  suspected  and  cannot 
Ije  found. 

9.  The  xcires  that  run  from  the  cells  to  the  buttons  of  the  current- 
selector  or  the  commutator  may  be  seen  on  the  bottom  side  of  the  key- 
board of  a  battery.  They  can  be  examined  for  imperfections  when  the 
other  parts  of  the  apparatus  appear  to  be  perfect. 

10.  Do  not  short-circuit  a  battery.  By  this  we  mean,  do  not  allow  a 
battery  to  run  down,  or,  more  technically,  "  polarize,"  b^-  the  poles  being 
brought  into  contact  without  an  interposed  hocXy  (such  as  animal  tissue) 
for  any  length  of  time.  For  example,  galvanic  cells  which  have  a  low 
internal  resistance  (as  a  Grenet  cell)  become  polarized  in  a  few  hours 
when  the  poles  are  connected  by  a  short  wire  which  affords  little  if  an}- 
resistance  to  the  current. 

11.  Keep  your  electrodes  clean,  ^s  I  have  stated  before,  it  is  well 
to  cover  them  with  fresh  canton-flannel  for  every  patient.  This  is  an 
act  of  precaution  which  will  impress  ix-ojile  with  your  regard  for  their 
feelings  and  for  their  safety  from  contact  with  infectious  matter.    Sponges 


STATIC  ELECTKICITY. 


647 


are  too  expensive  to  be  renewed  so  often.     Absorbent  cotton  may  often 
be  placed  between  the  electrode  and  its  covering  with  advantage. 

STATIC   ELECTKICITY.* 

An  exposition  of  the  ditl'erent  forms  of  generators  which  may  be 
employed,  and  the  various  methods  of  application  of  this  therapeutic 
agent,  together  with  hints  respecting  the  care  and  management  of  induc- 
tion machines  and  the  selection  of  apparatus,  seems  to  be  advisable  in  a 
work  of  this  character.  Most  works  on  medical  electricity  are  singularly 
deficient  in  this  field. 

We  owe  to  the  ingenuity  of  Otto  V.  Guericke,  the  inventor  of  the 
air-pump,  the  first  electrical  machine  where  friction  was  employed  as  the 


Fig.  164. — Hawksbfe's  Original  Electrical  Machine.  (From  Lecons  de  Physique  o(  the 
Abbe  Noliet,  published  in  1767  )  The  globe  is  of  glass,  and  positive  electricity  is  collected 
upon  a  conductor  suspended  by  silken  cords  from  the  ceiling. 

exciting  agent.  It  consisted  of  a  ball  of  sulphur  which  was  turned  upon 
its  axis  by  hand-power.  An  assistant  grasped  the  ball  with  his  hands, 
and,  by  so  doing,  served  as  a  conductor  for  the  escape  of  the  positive 
electricit}'^  to  the  earth.  This  primitiAC  aflfair  gave  feeble  sparks,  which 
could  only  be  seen  in  total  darkness. 

Hawksbee  substituted  later  a  globe  of  glass  for  the  ball  of  sulphur. 
He  obtained  more  satisfactory  sparks  with  the  positive  electricit}^  thus 
generated. 

Later  still  glass  tubes  wei-e  used,  with  hand  rubbing;  and  the}' 
entirely  superseded  the  globe  as  generators  until  the  middle  of  the 
eighteenth  century. 

*  A  portion  of  this  discussion  of  static  electricity  orisrinallj'  appeared  as  a  contribution 
to  The  Physician  and  /Si(rffeo7i,  Ann  Arbor,  Michigan,  1886. 


648 


LECTURES   ON   NERVOUS   DISEASES. 


In  llGT,  Hawksbee's  original  machine  was  revived  in  a  modified 
form  by  Prolessor  Boze,  of  Wittemheri; ;  and  for  a  time  it  came  into 
treneral  use.  The  cut  of  tins  machine  (Fig.  1G4)  is  taken  from  the 
Lecons  de  Flujmiue  of  Abbe'  Nollet. 

The  collector  was  hung  from  the  ceiling  by  silken  cords ;  and  the 
hands  of  an  assistant  were  used  as  rubbers  upon  tlie  globe  of  glass. 

In  1708,  llanisden,  of  London,  invented  the  so-called  "plate 
macliine."     The  glass  plate  was  supported  by  wooden  uprights,  and  the 


FiG.  16.j — Ramsden's  Electrical  Machine.  (Invented  in  1768.)  It  has  sector-shaped  pieces 
of  oiled  silk  to  prevent  a  loss  of  electricity  from  the  glass  plate  while  passing  from  cushion  to 
cushion. 


friction  was  made  by  means  of  two  cushion-rubbers.  The  collectors 
were  of  metal ;  and  two  combs  of  motal  were  employed  to  draw  off  the 
electricity  from  the  glass  plate.  The  cushions  were  "  grounded "  by 
means  of  metal  supports,  so  that  the  negative  electricity  which  accumu- 
lated upon  them  could  escape  to  the  earth.  In  17T6,  Yon  Marum  modi- 
fied Tlamsden's  appnratns  so  as  to  obviate  this  loss. 

Nairne  next  modified  the  machine  of  Enmsden  by  substituting  a 
cylinder  of  glass  for  a  single  glass  plate,  and  by  adding  an  attachment 
for  collecting  the  negative  electricity  by  means  of  an  insulated  conductor 


STATIC   ELECTRICITY. 


G49 


placed  in  communication  with  the  rubbers.  Tiiis  was  the  first  machine 
that  satisfactoi'ily  furnished  botli  positive  and  negative  static  electricity. 
Probably  the  first  electrical  apparatus  whicli  can  properly  be  said 
to  have  been  a  true  "  induction  machine  "  was  described  as  earl3'  as  1788, 
by  VV.  Nicholson,  before  the  Royal  Society  of  London.  He  called  it  tlio 
'•  electric  doabler.^^  It  was  built  somewhat  upon  tlie  plan  of  the  machine 
now  known  as  the  Toepler  model.  It  had  three  disks,  attached  to  a 
common  hub.  These  touched  upon  pins  of  metal  at  two  points  during 
each  revolution,  and  passed  between  two  pairs  of  insulated  metal  plates 
without  touching  them.  They  deposited  their  electricity  upon  a  metal 
ball,  which  they  also   passed  during  each  revolution.      This  ingenious 


Fig.  166. — Nairnf's  F.LECTnirAL    Machine. — The   cylinder  of  c'^ss   revolves   between   two 
separately  insulated  conductors,  one  attached  to  the  rubber  and  the  other  to  a  metal  cjn.b. 

little  instrument  could  to-day  be  made  quite  eflTective  by  slight  modifica- 
tions. For  some  unexplainable  reason,  it  was  apparently  thought  to  be 
of  little  value,  and  even  its  existence  is  not  mentioned  by  any  standard 
author  on  electrical  subjects  with  which  I  am  familiar.  A  cut  of  the 
machine  was  published,  however,  together  with  the  inventor's  description 
of  the  macliine,  in  an  old  work  entitled  the  "  New  Ro3'al  Encyclopedia 
of  Arts  and  Sciences."     (See  Figs.  167  and  168.) 

Lane  and  Adams  both  perfected  frictional  machines  during  the 
eighteenth  century,  in  connection  with  Avhich  the  Leyden  jar  was  used 
for  medical  purposes.  Some  of  the  cures  reported  by  these  crude 
machines  are  fully  as  startling  as  those  now  obtained  by  improved 
apparatus. 


650 


LECTURES   ON   NERVOUS   DISEASES. 


Ill  1840,  Sir  W.  Aiiustrong  devised  a  machine  by  which  the  friction 

of  cooled  steam  against  the 
sides  of  minute  orifices, 
through  which  it  escaped 
under  a  high  pressure,  be- 
came the  generator  of  static 
electricity.  The  boiler  was 
insulated  by  glass  legs,  aud 
liecanie  negatively'  electrified. 
The  jets  of  steam  conveyed 
the  positive  electricity  and 
deposited  it  upon  a  metal 
plate  studded  with  points, 
upon  which  the  jets  were 
directed.  This  machine 
proved  very  powerful,  but  dif- 
llcult  to  manage,  and  totally- 
unfit  for  general  use.  It  made 
a  deafening  noise,  and  satu- 
rated everything  near  it.  One 
of  these  machines  gave  a 
spark  of  twent3-two  inches. 

To  Holtz,  of  Berlin,  we 
do  not  owe  the  discovery  of 
the  first  induction-machine,  as 
ninny  suppose.  His  apparatus 
was  not  jierfected  until  18()5. 
Although  the  original  model  seems  crude  in  comparison  with  our  present 

instruments,  still  it  cannot  be  denied 
that  it  contained  the  principle  which 
formed  the  starting-point  of  all  the 
later  improvements ;  and  many  of 
the  meclianical  details  of  the  original 
instrument  are  to-day  generally  used. 
There  is  a  modified  form  of  an 
induction  machine  which  is  now  sold 
quite  extensivel}'  to  the  medical  pro- 
fession. It  is  known  as  the  Toepler 
machine,  or  the  Yoss  machine.  It 
can  be  made  with  one  or  more  re- 
volving plates.  The  fixed  plates  are 
larger  than  the  revolving  ones,  and 
They  may,  however,  be  divided  or  per- 


FiG.  1G7. — Nicholson's  "Elecikic  Doubler."  (The 
fust  induction  inachirie  invented  )  Keprodiiced  from 
the  original  cuts  made  in  the  eighteenth  century.  The 
lighter  poitions  of  the  cuts  are  made  of  glass. 


Fig.  16S. — The  samb  Mac  hine,  Viewed 
n«)M  Above. 


have  usually-  a  central  openiiu 


STATIC   ELECTKICITY. 


C51 


forated  contrally.*  They  are  furnished  with  paper  collectors  and  disks  of 
tin-foil.  Tlie  revolving  plates  have  metal  buttons  attached  to  one  of  their 
faces.  These  buttons  impinge  ui)on 
metal  brushes  as  the  plate  is  revolved. 
The  buttons  rest  on  tin-foil  cemented 
to  the  glass.  The  fixed  plates  are 
placed  as  close  as  possible  to  the  re- 
volving plates. 

It  is  claimed  that  this  machine 
will  work  in  all  weathers.  1  have  not 
found  this  to  be  strictly  fact;  al- 
though it  is  not  as  much  attected  by 
dampness  as  an  ordinary  plate 
machine. f  This  machine  is  usually 
not  encased, — a  defect  which  I  have 
remedied  with  satisfactory  results. 
It  is  lighter  and  less  expensive  than 
tlie  improved  patterns  of  the  Holtz 
model ;  but  it  is  far  less  satisfactorj^ 
in  medicine,  because  it  generates  a 
much  smaller  quantity  of  electricity 
and  has  less  intensity.  The  spark 
elicited  may  be  a  moderately  long- 
one  (when  compared  with  the  radius 
of  the  revolving  plates) ;  but  it  is 
rather  a  thin  spark  at  best,— thus  confirming  the  view  expressed  by  me 
respecting  the  quantity  generated. 


Fig.  169. — An  Appauatus  for  Giineuating 
Fkictional  Electkrityby  Sikam.  (De. 
vised  by  W.  Avmstrong) .  'I'he  legs  upoa 
which  the  boiler  rests  are  of  glass.  The 
negative  electricity  generated  by  the  ma- 
chine when  in  action  accunmlates  iijion 
the  boiler,  and  the  positive  electricity  is 
collected  by  thocomb  upoa  which  thesteam- 
jels  are  directed. 


« 


Fig.  170 — One  OF  tub  Oldest  Models  op  a  Cvlinukical  Static  Machine. — The  rubbers  are 
grounded,  and  a  l.eyden  Jar  is  connected  with  the  positive  electricity  stored  in  the  receiver. 

The  Principles  of  Static  Induction. — The  application  of  the  prin- 
ciples of  static  induction,  as  demonstrated  in  the  machine  devised  b}- 

*  I  have  latt'ly  liad  one  so  divided,  wiiich  works  admirably. 

t  This  opinion  is  supported,  moreover,  by  tbe  faet  tliat  some  manufacturers  of  these 
machines  give  to  their  purchas«rs  explicit  directions  respecting  the  drying  of  the  plates. 


652 


LECTURES   ON   NERVOUS   DISEASES. 


Iloltz.  is  diflicnlt  to  fully  explain  without  devoting  more  time  to  the 
general  subject  of  electrical  induction  than  is  deemed  wise.  It  may  l)e 
roughly  summarized,  however,  as  follows  : — 

Any  body  when  electrified  has  the  power,  to  a  greater  or  less 
extent,  of  exerting  (even  through  an  intervening  substance,  which  in 
this  instance  consists  of  a  plate  of  glass)  a  peculiar  effect  upon  the 
electrical  state  of  another  body  closely  adjacent  to  it  in  position.  It 
tends  to  draw  from  the  opposed  body  that  variety  of  electricity  which 
it  does  not  itself  possess.     Now,  if  an  intervening  substance  happens 


—  ^     i&sr 


Fig  171  —  The  Ohicinal  Modei,  of  Holtz's  Indiktion  Machine  with  Vertical  Plates. 
'I'he  s.-im-  inventor  also  perfected  a  machine  wiihoiit  win  iows  or  armatures,  in  which  two 
Iiorizontal  plates  revolved  in  opposite  directions.   This  machine  is  shown  in  a  subsequent  cut. 

to  exist  between  the  two  bodies,  the  electricity  drawn  toward  it  by  induc- 
tion may  be  deposited  upon  the  corresponding  side  of  that  substance, 
and  a  proportionate  amount  of  electricity  of  the  opposite  A'ariety  is 
abstracted  from  the  intervening  body.  Hence,  the  intervening  body  . 
becomes  either  positively  or  negatively  electrified  on  one  side,  as  the 
case  may  be. 

In  the  induction  machine,  the  intervening  substance  happens  to  be 
the  revolving  glass  plate ;  and  the  opposed  bodies  are  the  two  ])aper 
collectors  and  the  two  metal  combs  of  the  machine,  which  are  separated 
by  the  revolving  plate  of  glass. 


STATIC   ELECTEICITY. 


653 


In  all  induction  machines,  the  charge  is  pracliralhj  constant  icJien 
once  established,  provided  the  mechanism  be  perfect  and  the  plates  kept 
absolutely  dry.  Under  such  conditions,  it  ought  never  to  fail  to  produce 
its  full  effects  when  the  wheels  are  set  in  revolution.  This  is  a  great 
desideratum  in  medicine. 

In  the  original  lloltz  model  only  one  stationary  and  one  revolving 
plate  were  nsed.  Both  were  circular  in  shape.  The  stationary  plate  had 
openings  or  "  windows  "  cut  in  it.  Paper  collectors  were  glued  to  the 
stationary  plate,  so  made  as  to  project  Irom  it  and  to  come  in  close  con- 
tact with  and  to  face  the  openings  in  the  stationary  glass  plate.  The 
revolving  plate  was  insulated  by  legs  of  glass,  while  the  stationary  plate 
was  not.  Metal  combs  were  used  as  terminal  attachments  to  tlie  inner  end 
of  the  two  poles  of  the  machine. 
The}'  faced  the  revolving  plate 
and  almost  touched  it. 

You  will  find  all  of  these 
mechanical  features  practically 
preserved  in  the  improved 
models  of  to-day.  The  revolving 
and  stationary  plates  have  been 
increased  in  number,  simply  to 
augment  the  quantity  of  elec- 
tricit}^  generated.  The  sta- 
tionary plates  are  no  longer 
circular ;  the}'  are  made  in  two 
])ieces,  to  allow  of  "windows.*' 
Two  paper  collectors  are  glued 
to  each  stationary  plate.  These 
terminate  in  points,  which  pro- 
ject into  the  "  windows  "  made 
by   dividing    the    plates.      The 

poles  of  the  machine  have  metal  combs  on  one  end  and  a  brass  ball  at  the 
other.  Extra  combs  have  been  added  to  draw  off"  residual  electricity, 
which  accumulates  in  excess  ;  but  these  are  "  grounded." 

Furthermoi'e,  the  machine  has  been  encased,  simply  to  protect  it 
from  atmospheric  changes.  Cat-skin  rubbers  have  been  added.  Thoy 
are  of  use  only  as  a  means  of  exciting  the  plates  when,  from  any  cause, 
induction  shall  have  ceased.  We  call  them  the  "  chargers  "  of  the 
machine. 

There  have  been  many  mechanical  modifications  ninde  from  time  to 
time  of  the  original  model,  which  have  not  been  here  specified  by  me  ; 
but  as  they  do  not  in  any  way  aflTect  the  principle  of  electrical  induction, 
they  are  not  of  importance  in  this  connection. 


Fig.  172. — The  Stationary  Plate  op  the  Origi- 
nal    HOLTZ,     SHOWING     ITS     AuMATURES      AND 

Windows,    with  the    Projections   upon  the 
Armatures. 


654 


LECTURES   ON   NERVOUS   DISEASES. 


In  the  original  Iloltz  machine,  a  charge  was  primarily  effected  by 
rultbino-  a  piece  of  ebonite  briskly  witli  cat-skin  nntil  it  became  highly 
charged  witii  negative  electricity,  and  then  api)lying  it  closely  to  one  of 
the  paper  collectors  on  the  stationary  plate  of  the  machine.  By  the 
"  law  of  indnction  "  the  comb  opposed  to  this  paper  collector  becomes 
electrically  excited  immediately.  It  at  once  deposits  posiYtue  electricifif 
on  the  side  of  the  revolving  plate  nearest  to  the  comb,  and  takes  nega- 
tive electricifif  away  from  the  revolving  plate.  Thns  the  revolving  plate 
becomes  podtively  electrified  to  a  very  high  degree  at  this  point. 


Fig.  173. — Holtz's  Static  Induction  Machine,   with   Horizontai.  Plates. — The  plates 
have  neiii.er  winjuws  nor  armatures,  and  they  revolve  in  opposite  directions. 


Now,  when  the  wheel  is  made  to  revolve  to  that  point  where  it  meets 
the  other  paper  collector  upon  the  stationary  plate,  indnction  again 
takes  place.  Negative  electricity  is  deposited  (1)  by  the  collector  on 
the  opposite  side  of  the  revolving  plate  (the  side  nearest  to  the  paper 
collector),  and  (2)  by  the  metal  comb;  at  the  same  time  positive  elec- 
tricity is  taken  from  th^  adjacent  side  of  the  revolving  plate  by  the 
collector,  and  also  by  the  metal  comb,  from  the  opposite  side  of  the 
revolving  plate.  This  interchange  of  electricities  charges  the  ''  positive 
pole  "  of  the  machine. 

The  revolving  plate  (now  excessively  charged  with  negative  elef- 
tricity)  goes  on  to  the  next  paper  collector.     Here  a  similar  exchange 


STATIC    ELECTRICITY,  6o5 

of  electrical  conditions  occurs.  Tlie  negative  electricity  is  taken  front 
the  revolving;  plate  b}'  both  the  paper  collector  and  the  metal  comb,  and 
positive  electricity  is  given  to  the  plate  in  exchange  from  both  of  these 
sources.     Hence  the  ''  negative  pole  "  becomes  highly  charged. 

As  long  as  the  revolving  wheels  are  kept  in  revolution,  this  inter- 
change of  electricities  continues  at  each  of  the  poles;  hence,  the  accumu- 
lation at  each  pole  soon  becomes  sufficiently  great  to  allow  of  an  escape 
from  ])ole  to  pole  in  the  form  of  a  spark,  or  into  the  atmosphere  as  a 
"  luminous  brush  "  easily  seen  in  the  dark. 

STATIC   ELECTRICITY   AS    COMPARED   WITH   GALVANISM. 

It  has  been  computed  that  the  electro-motive  force  of  a  Holtz 
induction  machine  is  52,000  times  as  great  as  that  of  a  Daniell  cell  (or 
52,000  volts).     It  is  not  affected  b}^  the  velocit}^  of  rotation. 

The  quantity  generated  is  proportionate  to  the  velocity  of  rotation 
and  the  number  of  wheels  emplo3'ed.*  It  is  modified  also  by  the 
moisture  present  in  the  atmosphere. 

The  internal  resistance  of  the  machine  diminishes  rapidly  witli 
increased  velocit}'^  of  rotation.  It  is  not  influenced  by  atmospheric 
conditions. 

STATIC   ELECTRICITY   IN   MEDICINE. 

The  revival  of  static  electricity^  (or  franklinism)  as  a  therapeutical 
agent  from  the  oblivion  into  which,  for  nearly  half  a  century,  it  had 
unaccountably  sunk,  has  been  occasioned  b}^  several  factors.  Among 
these  factors  the  following  maj'  be  prominentl}'  mentioned  : — 

(1)  The  awakening  of  the  profession  at  large  to  the  fact  that 
electrical  currents  of  different  kinds  have  distinct  therapeutical  actions. 

These  are  not  to  be  attributed  to  or  confounded  with  the  strength 
of  the  current  emplo3^ed,  or  its  methods  of  application.  The  effects  of 
faradization,  galvanization,  and  franklinization  upon  animal  structures 
differ  widely  in  many  respects.  The  time  has  come  wlicn  an  intelligent 
physician  cannot  justly  condemn  all  forms  of  electrical  treatment  of  any 
individual  case,  because  he  has  foiled  to  obtain  satisfactory  results  witli 
one  of  the  above-mentioned  currents  alone  ;  even  if  he  has  emplo3^ed 
that  particular  form  of  current  with  the  highest  possible  skill  and 
judgment. 

This  is  an  eiTor  into  which  many  are  unwittingly  led.    I  could  report 

(if  space  would  permit  me  to  do  so)  the  details  of  several  cases  where  a 

failure  to  emplo\"  the  proper  current  proved  most  disastrous  to  patients. 

One  instance  of  this  character  (which  was  happil}"  aborted)  impressed 

me  so  forcibl}'^  at  the  time  that  it  is  possibly  worth  narrating: — 

*  On  this  account  I  have  lately  increased  the  size  of  the  driving-wheel,  so  as  to  insure 
rapid  revolution  of  the  plates  of  the  machine. 


656  LECTURES   ON   NERVOUS  DISEASES. 

A  p:iti(nt,  wlio  luul  acc'i<U'iit:illy  severed  the  musciilo-spiral  nerve  hy 
fi  pistol-bullet,  w:is  sent  to  ine  some  years  since  for  diagnosis,  and  to 
conlirm  or  reject  an  opinion  wliicli  had  been  expressed  by  a  physician 
of  prominence,  namely,  that  the  only  hope  of  enre  lay  in  a  surgical  oper- 
ation for  the  uniting  of  the  severed  ends  of  the  nerve  by  sutures.  This 
opinion,  as  I  found,  was  based  ui)on  the  f:\ct  that  the  faradaic  current 
had  failed  to  produce  any  movement  in  the  paralyzed  muscles,  and  that 
several  months  had  already  elapsed  since  the  accident,  during  which 
time  the  hand  was  steadily  becoming  more  and  more  deformed  by  con- 
tracture of  the  flexor  muscles  of  the  hand  and  forearm. 

My  examination  of  the  patient  showed,  however,  that  a  galvanic 
current  produced  violent  contractions  of  the  paralyzed  muscles  when 
passed  throurih  the  injured  nerve  (one  pole  being  placed  upon  the  ster- 
num as  a  neutral  point,  and  the  other  upon  the  musculo-spiral  nerve) ; 
and  the  galvanic  reactions  of  the  nerve  and  its  muscles  furthermore  indi- 
cated marked  '•  degeneration  "  as  having  developed  in  the  nerve  below 
the  point  where  it  had  been  divided.  Thus,  the  question  of  the  advisa- 
bilit}^  of  an  operation  was  decided  positivel}'  in  the  negative.  The  nerve 
had  already  united. 

In  about  eight  months  the  injured  nerve  was  completely  restored  1\y 
the  use  of  the  "  static  spark,"  the  contracture  had  disappeared,  and 
to-day  the  patient  can  see  no  diflTerence  in  the  usefulness  of  his  hands. 

(2)  The  improvements  tchich  have  been  made  in  machines  for  the 
generation  of  static  currents  for  medical  purposes  have  had  much  to  do 
with  the  revival  of  this  method  of  treatment. 

Some  of  the  cases  reported  in  the  earlier  enc3'clopedias  and  anti- 
quated works  on  electricity  are  fully  as  startling  as  those  now  encoun- 
tered when  treated  with  the  impi'oved  machines  ;  but,  on  the  other 
hand,  many  failures  to  obtain  good  results  must  of  necessity  have 
occurred  in  olden  times  from  the  imperfect  apparatus  depicted  in  the 
scientific  works  referred  to.  Later,  I  will  discuss  the  various  improve- 
ments which  have  been  made  from  time  to  time  since  Holtz  first  devised 
the  present  model  of  an  induction  machine  (1865). 

(3)  Improved  methods  of  administration  of  static  currents  have 
added  materially  to  the  effectiveness  of  this  agent  as  a  cure  of  disease. 
Some  of  these  methods  were  uidcnown  in  earlier  times  (as  far  as  mv 
research  goes  to  show). 

(4)  It  is  now  known  that  a  considerable  quantity^  as  well  as  length 
of  spark,  is  essential  to  the  successful  use  of  a  static  machine  in  medi- 
cine. Many  of  the  static  machines  sold  to-day  are  practically  worthless, 
save  as  a  toy,  because  they  do  not  produce  a  sutlicieut  quantity  of  elec- 
tricitv.  The  requisites  of  a  static  machine  for  medical  purposes  will  be 
touched  upon  later. 


STATIC   ELECTRICITY. 


657 


rS)  Experimentation  witli  tliis  agent  seems  to  Liave  confirmed  the 
views  of  its  enthusiastic  advocates  of  the  present  day,  and  to  support  the 
accuracy  of  many  of  the  observations  reported  in  old  scientific  works. 
The  incredulity  of  the  past  is  rapidly  being  overthrown  in  respect  to  this 
method  of  treatment ;  and  the  special  fields  in  which  it  proves  of  the 
greatest  service  are  being  definitely  mapped  out  b}-  those  who  are 
scientifically  recording  the  results  of  its  administration. 

For  the  past  few  years  I  have  devoted  considerable  attention  to  the 


Fig.  174 — Holtz  Induction  Machink,  as  Improved  by  the  Author. 

improvement  of  the  Holtz  Induction  ^Machine.  Some  of  the  results  of 
ni}'  experimentation  have  already  been  published.  The  machine  now 
described  (Fig.  174)  is  in  some  respects  an  improA'ement  npon  the  one 
which  I  originally  introduced  to  the  profession  through  the  Medical 
Record  of  October  17,  188.5.  I  have  modified  the  charger  originally  used 
by  me,  so  that  it  now  bears  upon  the  outer  revolving  plates  above  the 
metal  combs,  instead  of  passing  between  the  central  revolving  plates.  I 
have  found  that  the  application  of  cat-skin  at  this  point  on  the  outer 

43 


658 


LECTURES   OX   NERVOUS   DISEASES. 


plates  awakens  the  machine  into  action  (when  not  charged)  with  greater 
rapidity  and  certainty  than  at  an}'  other  part  of  the  machine.  Further- 
more, there  is  no  longer  an}'  dillicult}'  in  making  the  contact  between  the 
charger  and  the  glass  when  the  wheels  are  revolving  rapidly  ;*  while, 
with  the  old  charger,  the  springing  of  tlie  rubbers  often  rendered  their 
insertion  between  the  revolving  plates  (which  are  in  extremely  close 
approximation)  a  matter  of  some  little  annoyance  at  times.  This  modi- 
fication in  the  charger  has  entailed  a  slight  change  in  the  mechanism  by 
which  the  rubbers  are  brought  into  play  when  needed. f 

*A  slight  touch  of  the  charter  of  short  duration  upon  revolving:  wheels,  repeated  at 
intervals  of  a  second  or  two,  is  more  effective  than  a  long-continued  application  to  the 
wheels  of  an  induction  machine. 

t  In  some  models  of  the  present  day,  the  charger  cannot  be  raised  from  between  the 
revolving  plates.    This  is  a  serious  defect. 

Note.— The  following  description  of  this  machine  is  quoted  from  the  author's  article  in  the 
Medical  Record,  October  17,  iSSo  : — 

"  I  would  call  the  attention  of  the  profession  to  an  improved  static  machine  which  has  been 
lately  devised  by  me. 

•'It  is  the  result  of  many  months  of  experimentation,  and  is  the  outgrowth  of  the  dissatisfac- 
tion which  all  other  deviees"for  generating  electricity  by  f lictiou  h;ive  aiforded  myself,  as  well  as 
others  who  have  employed  them.  By  those  who  h;i  ve  h;i(l  experience  with  static  machines,  it  is  gen- 
erally conceded  that  they  are  frequently  charged  with  ditiicult>  and  give  but  a  tcebh-  spark  during 
damj)  weather ;  and  that  they  are  jjarticnlarly  unsatisfactory  and  ot  little  service  during  the 
sunnner  months,  when  such  conditions  are  liable  to  prevail.  It  is  also  conceded  that  some  form 
of  motor  is  generally  re(iiiired  to  run  a  machine  of  large  size,  because  the  hand  is  soon  fatigued 
in  overcoming  the  friction  of  the  plates  upon  the  rubbers,  in  addition  to  that  produced  by  the 
bearings  of  the  axle  and  the  belt  which  connects  the  driving-wheel  with  the  axle.  Furthermore, 
it  is  now  well  recognized  that  plates  of  large  size  (Hi  to  24  niches  in  diameter),  and  several  of 
them,  are  absolutely  essential  to  a  machine  which  i.s  intended  for  medical  use.  Small  single-plate 
maohines  do  not  give  sutlicient  quantity  or  length  ot  spark  to  be  of  any  practical  benetit  as  a 
curative  agent.  Again,  if  has  been  found  by  experience  that  building  a  glass  case  over  a  static 
machine  does  not  thoroughly  prntci-t  the  plates  ot  the  instrument  from  dampness.  Xo  cabinet- 
maker can  make  jomts  of  wood  wliich  will  not  admit  of  much  moisture  when  the  outside  air  is 
impregnated  with  it ;  and  chloride  of  lalciuui.  if  placed  within  the  case,  will  not  absorb  all  the 
dampiiess  that  enters  and  collects  upon  the  plates  and  metal  of  the  machine. 

"  I  found  by  experience  that  all  the  electrodes  of  a  static  machine  (being  insulated  by  glass) 
were  liable  to  be  easily  broken ;  and  that  the  poles  of  the  instrument,  when  by  accident  exposed 
to  outside  violence  or  a  blow,  were  also  liable  to  cause  a  breakage  of  the  glass  windows  in  the 
case  of  the  machine  (which  they  perforate  in  most  of  the  later  uiodels). 

"In  some  machines,  the  case  is,  moreover,  too  small  for  the  plates  and  allows  of  an  escape  of 
more  or  less  of  the  electricity  generated.  The  first  machine  which  1  made  upon  the  present  plan 
had  this  objection.  It  would  giye  the  operator  an  occasional  shock  in  consequence  of  this  defect 
when  the  hand  was  usetl  as  a  motor,  and  it  lost  a  large  percentage  of  the  volume  of  electricity 
generated  by  -'grounding  '  that  proportion  which  jumped  to  the  metal  parts  of  the  case. 

'•  Without  entering  further  into  numerous  difficulties  which  1  have  had  to  encounter  and 
overcome,  I  may  summarize  the  more  important  iuqjrovements  made  in  the  machine  shown  in 
the  accompanying  cut,  as  follows  :— 

"(1)  Tiie  case  is  so  constructed  that  all  of  its  "iomt?,  axe  packed  icith  soft  rubber  hef ore  its 
screws  are  tightened.  This  prevents  the  entrance  of  moisture  from  without,  and  makes  the 
machine  a  useful  one  at  all  seasons  of  the  year.  Soft  rubber  now  constitutes  the  best  packing 
tor  steam  apparatus,  and  is  also  used  in  hermetically  sealing  fruit-jars  in  preferancc  to  any 
known  material.  All  imperfections  in  the  joints  of  the  case  are  perfectly  sealed  in  this 
instrument. 

"  (2)  The  doors  of  the  case  are  so  arranged  as  to  be  drawn  tightly  in  contact  with  a  frame 
covered  with  soft  rubber  by  means  of  milled  screws. 

'•  (3)  The  glass  in  the  case  is  put  into  the  frames  with  putty,  which  is  impervious  to  air. 

"  (4)  The  poles  of  the  machine  perfcu-ate  the  wooden  portion  of  the  case,  instead  of  the  glass 
windows.  They  are  insulated  with  hard  rubber,  and  the  apertures  are  protected  bv  soft-ruliber 
packing  placed  between  hard-rubber  buttons  and  the  wood.  Thus  the  danger  of  breakage  of  the 
case  liy  accident  is  ileerease<l  without  impairing  its  impermeability  to  daiiipness  or  allowing  of 
leakage  of  the  electricity  generated  when  the  machine  is  in  use,  while  the  strength  of  the  case  is 
matenaUy  increased  by  this  modiHcation. 

'■  (5)  The  axle  is  so  built  as  to  reduce  the  friction  to  a  minimum  and  to  allow  of  its  being 
oiled  without  opening  the  case. 

"  ((i)  The  driving-wheel  is  very  large,  and  rests  upon  a  cast-iron  support.  This  insures  both 
ease  of  motion  and  durability. 

'•(7)  The  glass  plates  of  the  machine  are  nine  in  number.  Six  of  these  revolve,  and  three  are 
stationary.  Ihe  stationary  plates  are  of  peculiar  shape.  The  revolving  wheels  are  made  of 
carefully  selected  glass,  so  as  to  be  as  true  as  possible  and  bear  evenly  upon  tlie  rubbers  as  they 
revolve. 


STATIC   ELECTEICITY.  659 

Again,  although  chloride  of  calcium  is  not  reciuired  during  the 
cool  months  in  this  particular  machine  for  the  purpose  of  drying  the 
air  contained  within  the  case  (on  account  of  the  rubber  packing  between 
all  the  joints  of  the  case,  which  almost  hermetically  seals  it),  I  have 
found  it  desirable  to  use  this  or  some  other  means  of  artificially  drying 
the  plates  during  the  summer  months  ;  because  the  air  is  then  excessiA'cl}- 
laden  with  moisture.  To  allow  of  the  introduction  of  a  traj^  contain- 
ing chloride  of  calcium  without  opening  the  doors  of  the  case  I  have 
been  forced  to  modify  the  wood-work  of  the  machine  somewhat,  and  I 
have  also  raised  the  lower  level  of  the  stationary  glass  plates  about  two 
inches.  By  this  means  I  can  now  slide  a  tra}-  nearly  the  whole  width  of 
the  case  underneath  the  plates,  and  thus  expose  the  air  within  the 
case  to  a  large  absorbing  surface,  which  deprives  it  of  moisture  very 
rap  id  I}'. 

I  hope  in  time  to  so  perfect  ni}-  S3'stem  of  packing  the  joints  and  the 
openings  in  the  case  (entailed  by  the  parts  of  the  machine  Avhich  must 
of  necessity  perforate  it),  as  to  make  it  absolutely  air-tight  at  all  seasons 
of  the  3'ear.  When  this  feat  is  accomplished,  the  necessity-  of  chloride 
of  calcium*  or  an^'  artillcial  dr3'er  within  the  case  will  have  been  entirely 
dispensed  with ;  but  until  cabinet-makers  can  be  found  who  never  make 
mistakes,  or  a  better  material  than  highl}'  finished  and  shellacked  woodf 
can  be  obtainad  from  which  to  construct  the  framework  of  the  machine, 
I  fear  this  scheme  will  never  be  perfectly  accomplished.  Practicall}^, 
however,  this  necessity  is  not  so  great  as  it  might  at  first  seem ;  because 
during  the  summer  months  the  diffusion  of  static  electricity  into  the 
atmosphere  is  so  gi'eat  as- to  seriously  interfere  with  a  satisfactory  appli- 
cation of  this  agent  to  a  patient  b}^  the  methods  known  as  "  insulation," 

"  (8)  The  excitants  consist  of  cat-skin  rubbers  so  arranged  as  to  touch  the  outer  plates  when 
the  machine  loses  its  charge.  This  charger  is  a  great  improvement  over  all  others  previously 
employed  by  me.  aietal  buttons  are  also  placed  upon  the  outer  plates,  which  as  materially  assist 
in  charging. 

"  (9)  The  collectors  have  tinsel  attachments  which  aid  in  gathering  the  electricity  generated. 

"  (10)  The  electrodes  are  made  witli  handles  composed  of  hard  rvibber  instead'  of  glass. 
They  are  therefore  less  liaiile  to  lie  liroken,  and  are  as  perfectly  insulated. 

'•(11)  Each  machine  is  provided  with  three  pairs  of  Ijeyden  jars  of  different  sizes.  It  is 
arranged  also  with  hooks  upon  which  the  electrodes  may  be  Iuuil:  when  not  in  use. 

'■In  conclusion  1  would  say  that  I  have  produced  with  the  uiachine  here  described  (2-1-inch 
plates),  and  now  in  my  office,  a  spark  of  eleven  inches  in  length  during  a  muggy  day  in  August, 
when  most  static  machines  would  fail  to  charge.  It  runs,  after  a  few  turns  by  the  hand,  for 
nearly  a  minute  without  any  power,  and  generates  without  interruption.  Any  boy  of  seven 
yearsof  age  can  run  it  without  fatigue  for  lialf  an  hour. 

"The  machine  here  described  is  manufactured  liy  Waite  &  Bartlett.  of  New  York  City,  who 
have  l)een  industriously  occupied  for  several  mnutlis  in  perfecting  it  under  my  guidance. 

"The  cost  of  this  machine  has  l)een  materially  reduced  from  the  schedule  prices  of  other 
makers  for  similar  instruments,  rather  than  increased  by  the  improvements  made." 

*  In  several  instances  I  have  known  the  chloride  of  lime  sold  in  commerce  to  be  placed 
within  the  case  of  a  static  machine.  The  result  has  been  to  almost  ruin  the  metal  parts  of 
the  machine.  It  took  a  mechanic  nearly  a  week  in  one  instance  to  restore  the  effective- 
ness of  the  instrument. 

t  It  has  been  computed  that  lifty  coats  of  shellac-varnish  are  requisite  to  prevent  the 
penetration  of  gases  through  stone. 


G60  LECTURES   ON  NERVOUS   DISEASES. 

the  "  indirect  spark,"  and  the  "  static  wind,"  in  spite  of  a  perfect  gen- 
erator. Tliose  metliods,  as  well  as  other  forms  of  application  of  static 
eIectricit^^  will  be  described  later. 

In  other  respects  than  those  ennmerated,  the  modified  Holtz  induc- 
tion machine  introduced  to  the  profession  by  myself  some  time  since 
remains  practically  unaltered.  Its  etiectiveness  seems  to  have  been  pre- 
eminently satisfactory  to  those  who  have  nsed  it,  and  the  quantity  and 
length  of  spark  which  can  be  elicited  is  as  nearly  an  approach  to  the 
maximum  of  its  theoretical  quantity  and  power  as  could  be  hoped  for. 

No  static  machine  can  give  off  a  spark  greater  than  the  radius  of  the 
revolving  plates.  I  have  frequently  demonstrated  a  spark  of  eleven  and 
a  half  inches  from  a  wheel  of  twelve-inch  radius.  Furthermore,  I  think 
I  can  justly  claim  to  have  so  improved  all  previous  models  built  on  the 
original  Holtz  plan  as  to  insure  a  continuance  of  the  charge  throughout 
nine  months  of  the  year  without  recourse  to  artificial  means  for  drj-ing 
the  plates.  When  properly  cared  for  and  handled ,  there  is  little  necessity 
even  for  a  charger  during  these  months. 

Before  I  pass  to  the  consideration  of  static  electricity  as  a  thera- 
peutical agent,  it  may  be  well  for  me  to  state  that  the  cost  of  a  static 
induction  machine  with  plates  of  twenty  inches  diameter  or  over  must 
of  necessity  be  large  ;  although  the  cost  has  been  materially  reduced  of 
late  by  competition  and  improved  methods  of  manufacture. 

Again,  it  is  impossible  to  transport  a  static  induction  machine  from 
house  to  house  without  danger  of  breakage  and  the  employment  of  a 
cartman ;  hence  it  becomes  a  part  of  a  phj^sician's  office  outfit  only,  and 
cannot  be  used  in  medical  practice  except  by  bringing  the  patient  to  the 
machine  or  going  to  some  expense  and  risk  in  transporting  it. 

Finall3%  a  static  machine  of  the  induction  model  requires  a  certain 
amount  of  care ;  otherwise  the  etfectiveness  of  the  instrument  is  liable 
to  deteriorate,  and  its  component  parts  to  become  more  or  less  injured. 

There  is  another  form  of  static  machine  (already  described  as  the 
Toepler  model),  which  has  been  sold  extensively  to  the  profession.  It 
has  no  case  to  protect  it  from  the  atmosphere.  It  can  therefore  be 
more  readily  transported,  and  it  costs  much  less  to  manufacture  than 
the  induction  model ;  but,  on  the  other  hand,  it  is  far  less  effective,  and 
cannot  be  favorably  compared  with  the  more  expensive  machine  as  a 
part  of  a  physician's  office  outfit.  The  quantity  generated  by  such  a 
machine  is  necessaril}^  small ;  and  it  is  more  or  less  seriously  affected  by 
atmospheric  changes.  In  spite  of  the  fact  that  some  of  the  later  authori- 
ties on  electricity  speak  in  its  praise,  I  cannot  give  it  an  unqualified 
indorsement.  It  may  serve  the  requirements  of  scientific  institutions 
admirably  ;  but  it  is,  at  best,  but  a  make-shift  for  the  neurologist.  I 
think  that  I  am  sustained  in  this  opinion  by  those  who  have  had  experi- 


STATIC   ELECTEICITY.  661 

ence  with  the  two  models,  when  provided  with  all  their  latest  improve- 
ments. I  have  been  experimenting  for  some  months  to  devise  a  cheaj* 
static  machine  which  patients  can  nse  at  their  homes,  and  I  thiidc  I  have 
sncceeded  in  producing  a  tolerably  efi'ective  instrument ;  but  1  should 
never  advise  a  physician  to  purchase  one  I'or  his  own  use,  if  he  could 
afford  to  buy  an  improved  Holtz  induction  machine. 

A  Static  Outfit. — The  cost  of  an  improved  iuduetion  machine  of 
the  latest  pattern  varies  from  $250  to  $350,  according  to  the  size  and 
number  of  the  plates  ;  hence,  this  is  a  matter  to  be  carefull^^  considered 
before  purchasing  one.  It  is  advisable,  in  my  opinion,  to  have  not  less 
than  six  revolving  and  three  stationary  plates.  The  revolving  plates 
should  not  be  below  twenty  inches  in  diameter.  I  prefer  one  with 
twenty-four-inch  plates,  for  medical  purposes,  over  those  of  less  power. 

The  attachments  which  should  be  purchased  with  such  an  instrumeut 
comprise  : — 

(1)  An  insulated  j)latfoinn.  These  may  be  made  to  seat  one,  two, 
or  more  persons  at  a  time.  I  use  for  legs  the  heavy  glass  insulators 
employed  by  telegraph  companies  upon  their  poles.  They  are  very 
strong  and  cheap,  and  have  another  advantage,  namel_y,that  they  can  be 
screwed  up  and  down  upon  a  wooden  pin  which  perforates  their  central 
orifice.  This  admits  of  leveling  the  platform,  in  case  the  floor  of  the 
room  has  settled. 

(2)  A  set  of  electrodes.  This  item  comprises  a  large  and  small  brass 
ball,  a  metal  point,  a  wooden  point,  a  roller  of  metal  and  of  wood,  an 
umbrella-electrode,  some  sponge-covered  electrodes,  a  pistol-electrode, 
and  a  ring  to  hold  the  chain  away  from  the  patient  during  the  applica- 
tions.    The  handles  should  be  long,  and  made  of  hard  rubber  or  of  glass. 

(3)  A  set  of  brass  chains  of  vaiwing  lengths. 

(4)  A  set  of  hooks  for  attachment  to  tlie  ends  of  the  chains. 

(5)  A  set  of  heavy  insulated  rheophores  of  varying  lengths. 

(6)  Three  pairs  of  Leyden  jars  of  different  sizes.  I  use  those  of 
3-inch,  H-inch,  and  1-inch  diameter,  respectively. 

(7)  A  ivooden  chair  or  stool  which  fits  the  insulated  platform. 

(8)  A  connecting  brass  rod,  for  use  when  the  Lej'den  jars  are 
employed. 

(9)  Some  pieces  of  cat-skin. 

(10)  Several  bottles  of  well-selected  chloride  of  calcium. 

The  Care  or  an  Induction  Machine. — A  few  suggestions  of  prac- 
tical value  may  be  made  upon  this  subject. 

It  is  advisable,  in  the  first  place,  that  an  induction  machine  should 
be  placed  in  a  perfectly  dry  room,«'f//  lighted  by  the  direct  rays  of  the 
sun;  and,  when  possible,  in  close  proximity  to  a  window  which  shall 
allow  the  sun's  rays  to  fall  directly  upon  the  glass  plates  of  the  instru- 


662 


LECTURES   OX   NEIIVOITS   DISEASES. 


Carbon   Electrode,  round  end. 


One  and  a  quarter  inch  Brass  Ball. 


Rubifacient. 


Brass  Point  and  Chain-Holder.  Morton's  Pistol-Electrode. 

Fig.  175. — Electrodes  Employed  with  an  Induction  Machine. 


I 


STATIC   ELECTRICITY.  663 

mont.  By  this  step  we  obviate  dampness,  and  thus  insure  the  greatest 
eliectiveness  of  the  machine.* 

In  the  second  place,  the  metal  j^nrts  of  tlie  machine  ajid  the  metal 
electrodes  should  be  rubbed  biHakly  every  morning  with  dr}^  chamois-skin 
or  silk.  Accumulated  moisture  on  the  poles  or  electrodes  is  a  serious 
drawback  to  successful  static  applications. 

In  the  third  place,  although  the  metal  j^arts  of  the  machine  are 
shellacked  when  made,  they  are  apt  after  a  lapse  of  time  to  require 
repolisliing  with  emery-paper,  powdered  emery,  or  rotten  stone.  A  light 
coat  of  shellac-varnish  should  be  given  these  parts  after  their  brightness 
has  been  restored,  and  all  grease  or  moisture  thoroughly  removed  from 
them. 

Again,  it  becomes  necessary,  at  intervals,  to  oil  the  bearings  of  the 
wheel-axle  and  the  plate's  axle;  also  to  occasionally  tighten  the  leather 
belt,f  and  to  re-shellac  the  case  if  it  becomes  blistered  by  the  sun.  The 
latter  step  tends  to  exclude  the  entrance  of  moisture  within  the  case 
through  the  pores  of  the  wood. 

During  the  summer  months  fresh  ehloride  of  ealcium  should  he 
constantly  kept  ivithin  the  case.  It  should  be  renewed  Avhenever  sufficient 
fluid  appears  in  the  tray  to  become  evident  to  the  eye.  Unless  the  case 
is  packed  with  rubber,  this  method  of  artificiallj'  drying  the  air  must  be 
employed  at  all  seasons  of  the  3'ear.  A  few  drops  of  petroleum  on  the 
floor  of  the  case  help  to  prevent  the  accumulation  of  atmospheric 
moisture  upon  the  plates. 

Occasionally,  the  best  machine  will  lose  its  charge.  Should  it  do 
so,  you  will  probably  find  that  one  of  the  following  causes  has  led  to 
this  result  : — 

(1)  The  servant,  or  some  inquisitive  person,  may  have  turned  the 
revolving  j^lates  in  the  wrong  direction  ;  this  causes  the  accumulators  to 
lose  their  electrical  state  and  thus  to  arrest  "  induction  "  through  the 
glass  plates. 

(2)  Atmospheric  moisture  mm/  have  entered  the  case  and  been  depos- 
ited upon  the  plates.  In  all  models  that  I.  know  of,  but  my  own,  this 
occurrence  must  of  necessity  be  very  frequent,  as  no  safeguards  exist  to 
prevent  it. 

(3)  The  instrument  may  have  been  left,  after  an  application  to  a 
patient,  with  both  the  poles  "  grounded  "  by  means  of  the  cliains  dangling 
from  them  and  resting  upon  the  floor.  This  oversight  may  not  prove 
serious  in  dr}^,  cold  weather ;  but,  it  is  never  advisable  to  leave  the 
chains  attached  to  the  poles  when  the  instrument  is  not  in  use. 

*I  have  my  own  in  a  bay-window,  where  the  afternoon's  sun  has  free  access  to  it. 
t  Thumb-screws  beneath  the  driving-wheel  post  are  provided  for  this  purpose  iu  my 
model. 


664  LECTURES   ON   NERVOUS   DISEASES. 

(4)  The  plates  may  have  loosened  from  the  axle  ;  and,  in  conse- 
quence, some  \r\i\y  fixil  to  revolve  properly.  To  obviate  this  occurrence, 
doul)le  nuts  should  be  used  on  tiie  plate-axle. 

(5)  The  combs  via;/  have  become  displaced,  so  as  to  touch  the  glass 
or  to  bear  an  improper  relation  to  the  paper  collectors. 

(6)  Tlie  case  ma>j  be  too  small  for  the  plates  ;  and  thus  allow  of 
escape  of  the  electricity  to  the  ground.  This  will  be  very  apparent  to 
the  eye  when  tested  in  darkness. 

The  Charging  of  a  Machine. — It  is  well  to  know  what  steps  are 
necessary  to  start  a  static  induction  machine,  in  case  it  loses  its  charge. 
I  have  seen  a  few  instances  where  the  owner  of  such  an  instrument  has 
worked  himself  into  a  heat  of  passion  as  well  as  of  body  b\-  fruitless 
attempts  to  obtain  a  spark,  while  a  patient  calmly  waited  with  expec- 
tancy for  tlie  successful  termination  of  his  feat.  Some  of  ni}'  readers  maj- 
have  had  such  an  experience.  I  suggest,  therefore,  that  they  follow  the 
directions  given,  with  some  regard  to  their  details  : — 

(1)  See  that  the  plates  and  cha7-ger  ar'e  dry.  If  not,  you  can  easil^- 
render  them  so  by  exposing  the  machine  to  strong  sunlight,  and  by 
putting  an  al)undance  of  chloride  of  calcium  in  trays  at  the  bottom  of 
the  case.  This  may  require  some  hours  of  delay.  Always  open  the 
door  of  the  case  if  the  sun's  heat  be  used  ;  and  close  them  tightly  (by 
means  of  the  milled  screws  which  perforate  the  door)  as  soon  as  the 
machine  regains  its  charge.* 

(2)  After  \o\x  have  got  the  plates  thoroughly  diy,  start  them  in 
rapid  revolution  by  turning  the  driving-wheel  from  left  to  right  as  you 
stand  facing  it.  'Nov,-  apply  the  chargers  lightly  vear  to  the  edge  of  the 
revolving  wheels  for  a  second  or  txvo^  and  then  sweep  them  across  their 
face  at  intervals  of  a  few  seconds,  until  the  machine  starts.  The  poles 
should  be  approximated  to  witliin  one-half  inch,  and  the  chains  should 
not  be  connected  with  tlie  poles. 

(3)  If  the  machine  fails  to  start,  in  spite  of  these  directions,  you 
can  then  take  a  piece  of  cat-skin  and  warm  it  thoroughly  over  a  gas-jet. 
Tlien  set  the  wheels  in  rapid  revolution  and  appl}^  the  warmed  cat-skin 
as  a  rubber  (to  the  plate  witli  the  buttons  on  it)  as  close  above  the  metal 

*  If  you  cannot  spare  the  time  for  these  procedures,  a  large  alcohol-lamp  may  be 
lighted  within  the  case.  The  air  may  thus  be  heated  sufficiently  to  temporarily  render  the 
machine  useful.  I  am  aware  that  I  have  been  criticised  (in  a  carping  sjjirit)  for  offering 
this  suggestion  in  print ;  but,  as  a  temporarij  expedient,  it  oftentimes  proves  a  valuable  aid 
in  rapidly  regaining  a  lost  charge,  and  rendering  an  induction  machine  efficient. 

I  have  frequently  known  the  nozzle  of  a  hot-air  furnace  (such  as  is  used  in  giving  a 
hot-air  bath  to  a  patient  beneath  the  bed-clothes)  to  be  directed  into  the  case  of  an  induc- 
tion machine  for  the  purpose  of  drying  the  plates  when  very  damp.  Atone  time  I  tried  to 
build  a  machine  with  a  tube  passing  throusrh  the  case,  by  means  of  which  the  air  in  the 
case  might  be  heated  indirectly  witliout  opening  the  door;  but  I  found  it  impracticable, 
for  many  reasons. 


STATIC   ELECTEICITY.  665 

comb   as   it   is   possible   to  liokl  it.     This   seldom  if  ever  fails ;   but  it 
requires  the  opening  of  the  door  of  the  case. 

(4)  Be  sure  that  the  poles  are  xoell  dried  with  chamois-skin  before 
the  machine  is  put  in  action ;  also,  that  the  poles  are  closely  approxi- 
mated, but  not  in  contact. 

METHODS   OF   APPLICATION   OF   STATIC   ELECTKICITY. 

Static  electricity  can  be  applied  in  several  ways  to  a  patient.  Each 
of  these  methods  has  some  therapeutic  effects  which  are  peculiarl}^  its 
own.  Moreover,  the  sensations  experienced  by  the  patient  during  the 
application  are  greatly  modified  by  the  method  employed.  For  these 
reasons,  it  is  necessary'  to  go  into  greater  detail  respecting  the  manage- 
ment of  a  static  machine  than  tliat  of  any  other  electrical  apparatus  in 
medicine  with  which  I  am  familiar. 

We  can  apply  the  static  current  to  a  patient  in  the  following  ways  : — . 

(1)  By  the  ^'•indirect  spark.''^ 

(2)  By  the  "  direct  sparks 

(3)  By  the  "  Leyden-jar  spark  "  or  "  static  shock.'''' 

(4)  'By '■'■  static  insulation.'''' 

(5)  By  the  "  static  breeze.'''' 

(6)  By  the  "'■static  induced  current.'''' 

The  Indirect  Spark.  —  To  administer  static  electricity  by  this 
method,  tiie  patient  is  first  placed  upon  the  insulated  platform,  and 
sufficiently  removed  from  all  surrounding  objects  to  prevent  the  escape 
of  the  charge  from  the  patient  to  them.  The  machine  is  then  connected 
with  the  patient  by  a  chain,  which  is  either  held  or  simplj^  attached  to 
the  stool  on  which  the  patient  sits.  The  chain  must  be  sufliciently 
elevated  from  the  floor  to  prevent  "  grounding  "  of  the  current.  It  may 
be  attached  to  either  the  positiA'e  or  negative  pole  of  the  machine, 
according  as  the  operator  may  desire  positive  or  negative  insulation. 
A  chain  is  then  attached  to  the  other  pole  of  the  machine,  and  is 
"  grounded."  This  can  best  be  effected  by  attaching  it  to  the  gas-fixture 
or  a  faucet  attached  to  a  constant  water  supply.  If  this  is  not  conveni- 
ent, the  chain  may  be  thrown  upon  the  floor,  when  not  carpeted,  in  case 
the  generating  power  of  the  machine  is  ample. 

T\\Q  poles  of  the  machine  are  now  tvidely  separated  and  the  wheels 
put  in  rapid  motion.  You  will  notice  that  the  hair  of  the  patient  imme- 
diately rises  ;  and,  in  a  dim  light  or  total  darkness,  you  should  perceive 
a  peculiar  purplish  light  escaping  from  the  tips  of  the  finger-nails,  the 
hair,  and  other  parts  of  the  body  which  are  more  or  less  pointed.  The 
rapidity  of  this  escape  is  influenced  (1)  by  the  extent  of  the  charge; 
(2)  by  the  proximity  of  a  part  to  some  surrounding  object;  and  (3)  by 
the  condition  of  the  atmosphere,  as  regards  its  moisture.    As  the  patient 


666 


LECTURES  ON  NEEVOUS  DISEASES. 


moves  liis  finp:or-tips  mwr  tho  <loor-c:isin<>;  or  some  article  of  furnitnre 
not  insnhited,  you  may  be  uble  to  perceive  tliis  esctipe  of  electricity,  even 
in  a  strong  light. 

Now  we  have  a  condition  which  is  knoAvn  as  "  static  insulation." 
If  the  machine  is  a  powerful  one,  it  may  be  carried  to  a  high  point.  The 
patient  happens  to  be  charged,  in  Fig.  17G,  with  positive  electricity, 
because  he  is  connected  with  the  positive  pole  of  the  machine. 

The  final  step  consists  in  presenting  to  the  part  which  you  wish  to 
influence  a  brass  ball  on  the  end  of  an  insulated  handle.  This  electrode 
is  connected,  as  you  see,  with  a  gas-pipe  by  means  of  a  brass  chain.  A 
water-pipe  makes  an  equally  good  connection.  When  this  ball  reaches 
a  certain  degree  of  proximity  to  the  patient,*  3'ou  notice  that  a  discharge 


Fig  176. — The  Indiukct  Spakk. 

of  the  accumulated  electricity  occurs  in  the  form  of  a  "  spark."  This  is 
known  as  the  "  indirect  spark,"  because  the  electricity  takes  an  indirect 
course  (through  the  earth)  to  form  a  circuit.  It  leaps  from  the  patient 
and  escapes  to  the  earth  down  the  gas-pipe  or  whatever  grounding  the 
electrode  may  chance  to  have. 

The  length  of  tlie  "  indirect  "  spark  is  directly  proportionate  to  the 
generating  power  of  the  machine — supposing,  of  course,  that  all  other 
factors  in  the  application  are  equal  (such  as  the  humidity  of  the  atmos- 
phere, the  completeness  of  insulation,  etc.). 

*The  lensjth  of  the  ppark  elicitcil  depends  on  the  power  of  tlie  macliine,  the  dryness 
of  the  atmosphere,  and  tlie  perfection  of  the  insulation  of  the  patient.  I  frequently  have 
drawn  a  spark  of  cio;lit  inches  by  this  method. 


STATIC   ELECTKICITY.  667 

The  volume  of  the  spark  is  modified  by  the  size  of  tJie  braids  hall  on 
the  end  of  the  electrode.  A  large  ball  will  produce  a  heavier  spark  than 
a  small  one. 

The  therapeutical  effects  of  this  method  of  application  will  be  dis- 
cussed later.  I  would  call  attention,  however,  to  the  violent  muscular 
contractions  which  occur  with  each  spark. 

This  method  is  somewhat  painful.  The  withdrawal  of  a  spark  leaves 
a  "  weal "  or  lump,  which  somewhat  resembles  a  recent  mosquito-bite. 
They  almost  entirel}'  disappear  when  friction  is  employed  after  the 
application;  hence,  it  is  my  custom  to  rub  the  part  with  my  handker- 
chief, if  exposed  (the  face  or  hands,  for  example),  after  the  application. 

I  would  caution  you  here,  in  passing,  against  giving  static  sparks 
(by  any  of  the  three  specified  methods)  to  a  patient  on  his  first  visit. 
You  are  apt  to  frighten  a  patient,  unless  he  is  well  prepared  for  it. 
Again,  patients  grow  tolerant  of  this  method  of  treatment  after  a  while  ; 
hence,  you  can  gradually  increase  the  volume  and  length  of  spark  at 
successive  sittings  without  endangering  the  patient's  confidence  in  jou 
or  creating  alarm.  You  can  regulate  the  length  of  the  spark  by  the 
speed  of  revolution  of  the  plates  of  the  machine. 

For  some  hours  after  such  an  application  the  patient  feels  a  sense 
of  heat  at  the  spot  where  the  spark  occurred.  This  is  not  at  all  unpleasant 
to  many.     Some  patients  even  speak  of  it  as  agreeable. 

B3'  using  a  wooden  hall  in  place  of  a  brass  one,  a  number  of  very  fine 
sparks  are  simultkneousl}^  elicited — giving  to  the  patient  a  feeling  aptly 
compared  to  a  "shower  of  sand."  This  electrode  is  admirabl}'  adapted 
for  use  about  the  eye  or  the  face,  although  this  is  not  the  limit  of  its 
usefulness. 

Finally,  it  is  not  essential  to  this  form  of  application  the  that 
clothing  be  removed  ;  as  the  finest  silk  or  woolen  fabric  is  not  injured  by 
it.  This  is  a  great  point  in  favor  of  static  application,  especially  in  the 
treatment  of  females. 

It  is  customary  to  use  a  second  electrode  with  a  iHng  of  brass 
attached  to  the  insulated  handle,  through  which  the  chain  is  passed 
before  it  is  attached  to  the  ball-electrode.  This  is  to  keep  the  chain 
away  from  the  patient,  so  that  sparks  will  not  be  caused  at  points  where 
you  do  not  desire  them  to  occur.  A  little  practice  will  enable  j'ou  to 
handle  both  with  one  hand,  while  you  turn  the  wheels  of  the  machine 
with  the  other.  Sometimes  it  may  be  necessary  to  have  the  patient 
stand  rather  than  sit  upon  the  insulated  platform  while  these  applications 
are  being  made. 

Let  us  pass  now  to  the  second  method  enunciated. 

The  Direct  Spark. — By  this  method,  the  circuit  between  the  poles 
of  the  machine  included  the   patient  only.     He   sits  on  the  insulated 


668 


LECTURES  ON  NERVOUS  DISEASES. 


platform,  which  is  connected  with  one  pole  of  the  machine  ;  or  one  pole 
may  be  directly  attached  to  some  particular  extremity  of  tiie  patient, 
when  the  etlects  of  the  current  are  to  be  concentrated  as  mucli  as  pos- 
sibk'  upon  that  member.  The  electrode  is  attached  to  a  chain,  which  is 
fastened  to  the  other  pole  of  the  machine.  The  length  of  spark  to  be 
administered  is  regulated  by  the  extent  of  sejiaration  of  the  poles  of  the, 
machine  and  the  speed  of  revolution  of  the  plates.  The  farther  apart 
the  poles,  the  longer  and  more  severe  is  the  spark. 

The  ring  electrode  is  employed  (as  in  the  former  method)  to  i)rotect 
tlie  patient  from  an  accidental  contact  with  the  chain  attached  to  the 
electrode. 

In  neither  this  nor  the  method  previously  described  are  Leyden  jars 
emplo3"ed. 


Fig.  177  — The  Dikect  Spark. 

I  question,  personally,  whether  the  selection  of  the  poles  for  the 
attachment  of  the  electrode  has  much,  if  any,  influence  over  the  thera- 
peutical action  of  the  "  direct  "  spark.  If  it  has,  I  have  not  as  yet 
clearly  formnlated  in  my  own  mind  any  deduction  respecting  this  point. 

Static  Shock,  or  the  Leyden-Jar  Spark. — This  method  of  appli- 
cation is  accomplished  by  first  otfacJivu/  a  pair  of  Leyden  Jars  to  the 
poles  of  the  machine,  and  connecting  their  outer  covering  of  tin- foil  b>j  a 
brass  rod. 

The  poles  of  the  machine  are  then  brought  into  close  approxima- 
tion;  because  the  strength  of  the  shock  is  modified  (1)  by  the  size  of  the 
jars^  and  (2)  hy  the  separation  of  the  poles. 


STATIC  ELECTRICITY. 


669 


As  this  method  is,  fit  best,  a,  very  severe  form  of  application,  it  is 
■well  to  Legiu  "with  very  small  jars,  and  to  place  the  poles  as  nearly  in 


Fig.  its. — Shock  with  I.eyden-Jar  Discharge. 

oontact  as  possible  (without  actually  touching  each  other).     They  can 
then  be  separated  at  will,  as  the  exigencies  of  the  case  seem  to  demand. 
The  chains  are  arranged  in  a  similar  manner  to  that  described  in 
the  preceding  method  (direct-spark  application). 


Fig.  179.— An  Application  of  the  I.eyden-Jar  Shock  During  the  Eighteenth  Century. 
(Copied  from  an  old  English  work.) 

This  method  is  best  applied  to  the  bare  skin.     The  polarity  of  the 
electrode  is  not,  to  my  mind,  a  matter  of  much  consequence. 

I  advise  you  to  handle  this  form  of  treatment  with  extreme  caution. 


670 


LECTURES   ON   NERVOUS   DISEASES. 


I  liiive  several  times  accidentally  received  a  moderate  static  shock,  and 
I  can  assure  3^ou  it  is  not  associated  witli  pleasurable  sensations. 

Static  Insulation. — This  method  has  already  been  described  in 
connection  with  the  administration  of  the  •'  indirect  spark."  It  is,  per- 
haps, the  most  agreeable  of  all  methods  of  static  treatment.  The  patient 
is  simply  charged  for  a  variable  space  of  time  (three  to  twenty  minutes) 
with  either  positive  or  negative  electricity.  The  pole  of  the  machine  is 
attached  to  the  insulated  platform  on  which  the  patient  sits  or  stands. 
The  other  pole  is  "  grounded  "  by  a  brass  chain  running  to  the  floor,  a 
water-pipe,  or  a  gas-tixture. 

The  jjoles  of  the  machine  are  as  widely  separated  as  possible  before 
the  wheels  are  set  in  revolution. 


Fig.  180. — Static  Insulation. 


No  pain  is  experienced.  The  hair  becomes  erect,  unless  very  much 
oiled.  The  patient  experiences  a  peculiar  "tingling  sensation,"  with  a 
tendenc}'^  toward  perspiration  if  the  administration  is  long  continued. 
If  3'ou  approach  the  patient  too  closely,  a  spark  is  elicited  at  the  nearest 
point.     This  should  be  avoided,  if  possible. 

Its  therapeutical  effects  will  be  discussed  later. 

The  Static  Breeze. — This  method  of  administration  of  static  elec- 
tricity consists  in  the  withdrawal  of  the  static  charge  from  a  jjatient  by 
means  of  an  electrode  of  metal  or  loood,  which  is  pointed. 

If  the  breeze  be  indirectly  induced,  this  electrode  is  grounded  by  a 
chain  attached  to  a  gas-pipe,  a  watei'-faucet,  or  placed  in  contact  with  a 
wood  floor  when  the  other  connections  are  not  easily  accessible.     The 


STATIC  ELECTKICITY. 


671 


patient  is  first  insulated  (in  order  to  retain  a  charge),  and  is  then  con- 
nected with  one  of  tlie  poles  ot  the  machine  by  means  of  a  cliain,  which 


Fig.  ISl. — The  Indirect  Static  Breeze. 


he  either  holds  or  fastens  to  the  platform  upon  which  he  sits.     The 
electrode  is  then  employed. 


Fig.  182. — The  Direct  Static  Breeze. 


When  the  breeze  is  directly  mducedj  the  insulated  stool  is  connected 
with  one  pole  of  the  machine,  and  the  electrode  with  the  other  pole 


672 


LECTURES   ON  NERVOrS   DISEASES. 


If  the  electrode  be  a  metal  one,  the  electricity  Is  drawn  rapidly  from 
the  patient  at  the  point  which  is  nearest  to  the  electrode,  and  a  sensation 
resembling  that  of  a  breeze  is  experienced  at  the  spot  where  tlie 
electricity  escapes.  Single  or  multiple  points  may  be  employed  on  the 
electrode.  ^ 

In  either  of  these  methods,  when  the  electrode  is  composed  of  tvood, 
the  sensation  is  modified,  to  a  certain  extent,  by  the  poor  conductivity 
of  the  wooden  point.  Most  patients  compare  the  effect  of  such  an  appli- 
cation to  a  "  shower  of  sand  "  concentrated  upon  the  point  of  withdrawal 
of  the  charge. 

When  this  method  is  employed  about  the  eye,  the  wooden  ball  or 
wooden  point  is  usually  preferable  to  one  of  metal. 


Fig.  1S3. — The  Electrical  Head-Bath,  a  Variety  of  Administration  of  the  Static  Breeze. 

When  application  to  the  head  and  scalp  are  deemed  requisite,  a 
metal  cap  studded  Avitli  points  is  hung  over  the  head  of  the  patient  by  a 
chain,  wdiich  is  grounded.  This  cap  is  known  as  the  "  umbrella  elec- 
trode." It  should  not  touch  the  patient's  head  or  hair,  when  he  is  placed 
beneath  it  upon  the  insulated  platform.  The  numerous  points  of  the 
electrode  draw  oft"  the  electricity  through  the  hair  and  scalp,  which  passes 
from  the  machine  to  the  patient,  and  produce  a  sensation  which  is  i)ar- 
ticularly  pleasant.  A  "  strong  wind  "  is  felt  permeating  the  hair  and 
encircling  the  head. 

Static  Ixduced  Current. — To  convert  a  static  machine  into  what, 
to  all  practical  purposes,  may  be  considered  a  "Faradaic"  instrument, 
some  slight  modifications  only  are  required. 


STATIC   ELECTRICITY. 


673 


The  discovei\y  of  this  method  may  justl}^  be  attributed  to  the  inves- 
tigations of  Professor  W.  J.  Morton,  of  New  York ;  although  Matteucci 
lirst  devised  an  instrument  whioli  gave  shocks  by  induction  simulta- 
neously with  the  discharge  of  a  Leyden  jar.  (See  Fig.  795  of  Ganot's 
work  on  "  Ph^^sics,"  by  Atkinson.) 

To  produce  this  form  of  current,  it  is  necessar}"  to  first  hang  a  pair 
of  Leyden  jars  upon  the  arms  of  the  machine.  The  size  of  the  jars 
employed  modifies  the  strength  of  the  current ;  hence  it  is  necessary  to 
have  jars  of  different  sizes  as  a  part  of  the  static  outfit.  You  now  attach 
the  chains  or,  by  preference,  insulated  wires,  which  serve  to  connect  the 
machine  with  the  patient,  upon  the  hooks  that  rest  upon  the  outer  coating 
of  the  jars.  Finall}^,  you  attach  to  the  other  end  of  each  rheophore  an 
electrode  for  use  upon  the  body  of  the  patient.     The  electrodes  may  be 


Fig.  1S4  — The  Static  Induced  Current. 

of  metal  without  any  covering,  or  ordinary  sponge-covered  electrodes 
may  be  employed  (care  being  taken  that  the  insulating  handles  are 
somewhat  longer  than  usual). 

Before  the  machine  is  set  in  motion,  r7s  poles  should  be  approximated 
closely.  This  step  is  important,  because  the  separation  of  the  poles  inten- 
sifies the  current,  as  long  as  a  spark  will  pass  between  them.  There  are 
two  factors,  therefore,  in  determining  the  strength  of  the  static-induced 
current : — 

(1)  The  size  of  the  jars. 

(2)  The  extent  of  separation  of  the  poles. 

Dr.  Morton  has  devised  an  ingenious  electrode  which  allows  of  an 
application  of  this  form  of  current  to  a  patient  without  disturbing  the 
poles  of  the  machine;  but  it  is  not  an  essential  part  of  a  static  outfit, 
because  an  interruption  of  the  current  can  be  accomplished  without  it. 

43 


674 


LECTURES    ON   NERVOUS   DISEASES. 


This  electrode  represents  n  simple  nieclianic:il  lueMiis  of  putting  into 
practice  the  method  discovered  by  him  in  1880,  of  converting  the  static 
electric  charge  into  dynamic  electricity  or  current.  Electric  nerve-and- 
muscle  reactions  had  previously  been  obtained  by  means  of  the  inter- 
rupted galvanic  and  the  faradaic  currents.  It  has  also  been  noticeable 
that  the  "  spark  "  discharged  on  a  nerve  motor-point,  or  over  a  muscle, 
produced  the  characteristic  reactions.  But  the  spark  was  painful,  and 
ditlicult  to  direct  accurately,  particularly  about  the  face  and  head.  To 
avoid  these  objections,  Dr.  Morton  arranged  this  electrode,  by  means  of 
which  the  disruptive  discharge  or  spark  of  static  electricity  takes  place 
between  two  brass  balls,  one  of  which  is  in  relation  with  the  "  ground," 
while  the  other  is  connected  to  an  ordinary  moist-sponge  electrode. 
This  in  turn  is  applied  at  the  point  desired  of  the  patient  charged  on  the 
insulated  platform. 

As  a  result,  for  every  static  discharge  occurring  between  the  two 
brass  balls  there  is  a  dynamic  discharge  or  current  at  the  point  where 


Fig.  1S5. — Morton's  Pistol-Electrodb. 

the  sponge  is  applied,  and  the  nerves  and  muscles  may  be  stimulated,  or 
rather  "  irritated,"  exactly  as  by  the  ordinary  interruptions  of  battery 
currents,  direct  or  induced. 

This  electrode  is  another  means  of  converting  static  into  dynamic 
electricity,  based  npon  the  principle  described  under  the  name  of  "  static 
induced  current"  by  Dr.  Morton. 

This  "  static  induced  current,"  as  has  been  already  stated,  was 
obtained  hy  attaching  ordinary  sponge  electrodes  by  their  connecting 
rods  to  the  outer  layer  of  tin-foil  on  the  Leyden  jars.  The  patient,  in 
other  words,  replaced  the  usual  connecting  rod  between  these  coatings. 
On  putting  the  raachine  in  motion  and  causing  a  spark  between  the 
poles,  a  "  current  "  was  felt  hy  the  patient,  no  insulation  of  course  being 
required.  The  advantage  of  this  method  is  that  the  ordinary  Holtz 
machine  may  when  required  be  called  upon  to  perform  the  work  of  an 
ordinary-  faradaic  or  induction  machine. 

The  greatest  event  after  its  discovery,  in  the  history  of  medical 


ELECTRO-THEKAPEUTICS.  675 

statical  electrization,  or  franklinism,  was  tlie  invention  of  the  Holtz  or 
induction  machine  in  18()5.  Next  in  importance,  perliaps,  is  the  method 
discovered  and  put  into  practice  by  Dr.  Morton,  in  1880.  of  converting 
the  static  discharge  into  a  dynamic  discharge  or  current,  and  the  electrode 
represented  on  opposite  page  is  the  only  novel  electrode  of  any  importance 
not  beciueathed  to  us  by  the  medical  electricians  prcA'ious  to  1880. 

Tlie  difference  between  the  "  static  induced  current "  and  the 
ftxradaic  current  is  this:  The  former  has  a  fixed  polarity  and  direction, 
and  greater  electro-motive  force.  It  is  far  less  painful,  also,  than  is  the 
faradaic  current  when  the  electrodes  are  widely  separated. 

My  attention  has  lately  been  drawn  by  Dr.  Morton  to  another  device 
of  his  for  the  prevention  of  the  escape  of  sparks  from  a  sponge-covered 
electrode  while  employing  the  static  induced  current.  It  consists  in 
applying  a  coil  of  copper  wire  closely  upon  the  flat  surface  of  the  metal 
end  of  the  electrode  which  is  covered  by  the  sponge.  This  is  done  in 
order  to  prevent  the  concentration  of  the  current  at  an}'  one  point  on  the 
surface  of  the  electrode  while  in  use. 

He  has  also  been  experimenting  of  late  upon  the  effects  of  deriving 
currents  for  medical  purposes  from  a  helix  of  insulated  wire  wound  upon 
each  of  the  Leaden  jars  of  a  Holtz  induction  machine. 

I  have  not  yet  tested  the  working  of  either  of  these  later  appliances 
but  I  shall  do  so  soon,  when  I  am  provided  with  the  necessary  apparatus. 

PART   II. 

ELECTRO-THERAPEUTICS. 

Galvanic  Measurement  and  Dosage. — Quite  an  active  discussion 
of  this  important  subject  has  been  indulged  in  through  the  columns  of 
various  journals  during  the  past  j'ear.  Prominent  among  the  i)artici- 
pants  in  this  discussion  may  be  mentioned,  Drs.  Rockwell,  Martin, 
Engelmann,  Massey,  and  Bailey. 

The  fact  must  be  apparent  to  any  one  who  has  watched  the  progress 
of  electro-therapeutics  Avith  interest  that  the  professional  mind  is  at  last 
becoming  keenly  alive  to  the  necessit}'  c)f  knowing  exact!}'  how  much 
electricity  is  being  administered  to  a  patient  at  each  sitting.  The  method 
commonly  employed  in  the  past  of  noting  the  number  of  cells  used  (even 
this  precaution  not  being  always  taken  b}^  some  writers)  is  only  an 
approach  to  a  scientific  record  of  a  case.  It  off'ers  no  opportunity  for 
advancement  in  our  efforts  to  bring  electro-therapeutics  to  a  tangible 
basis  of  scientific  precision. 

A  few  hints  previously  offered  respecting  the  important  subject  of 
galvanic  dosage  may  therefore  be  repeated  here  with  possible  benefit  to 
the  reader. 


676  LECTURES   ON   NERVOUS   DISEASES. 

Galvanic  cells  tliller  in  their  electi'O-motive  force  according  to  their 
mechanical  construction,  viz.,  the  character  of  the  elements  employed, 
the  internal  resistance,  etc.  On  the  other  hand,  the  quantitu  generated 
depends  upon  the  size  of  the  elements  or  the  extent  of  their  immersion, 
and  the  character  of  the  excitant,  when  all  other  conditions  are  practi- 
cally similar. 

For  example,  two  galvanic  cells  of  identical  make  and  size  will  not 
generate  the  same  quantitj'  when  one  has  been  exhausted  and  the  other 
has  been  freshly  filled  ;  or  when  one  is  polarized  and  the  other  is  not 
polarized. 

The  electro-motive  force  has  no  relationship  with  the  size  of  the 
elements,  but  the  quantity  generated  has,  A  stream  may  flow  five  miles 
an  hour,  be  it  a  brook  or  a  river ;  but  the  quantity  of  water  that  passes 
a  given  point  in  the  same  interval  of  time  is  not  the  same  in  each  case, 
as  the  merest  child  can  easil}'  understand.  On  the  other  hand,  a  lake  at 
a  height  of  one  hundred  feet  will  exert  no  greater  pressure  through  a 
pipe  leading  from  it  to  the  ground  than  would  a  tea-cup  at  the  same 
elevation,  if  kept  constantly  filled.  The  quantity  is  determined  in  the 
first  instance;  the  pressure  (or  electro-motive  force)  is  illustrated  in  the 
latter.  The  bursting  of  water-pipes  in  our  dwellings  is  not  induced  by 
the  size  of  the  distributing  pipe  nor  hy  the  size  of  the  reservoir,  but  by 
the  height  of  the  original  source  of  supply. 

Again,  a  bullet,  when  propelled  from  a  weapon  with  a  given  charge 
of  powder,  will  penetrate  a  board  more  deeply  than  a  piece  of  iron.  So  it 
is  with  electric  currents.  A  current  of  a  definite  electro-motive  force 
will  travel  faster  through  some  tissues  than  others ;  will  penetrate  the 
skin  of  a  thick  palm  with  greater  diflficulty  than  the  thin  skin  on  the 
back  of  the  hand ;  will  be  facilitated  in  its  passage  by  large  elec- 
trodes and  retarded  in  proportion  as  their  size  is  reduced  ;  will  be 
aided  in  many  instances  by  the  satui-ation  of  the  electrode  (especially 
with  a  saline  solution),  and  will  be  retarded  by  the  absence  of  such 
conditions;  will  be  aided  by  a  close  approximation  of  the  electrode  to 
the  surface  of  the  body,  and  retarded  by  an  imperfect  approximation  of 
the  electrode. 

Currents  derived  from  a  galvanic  battery  invariably  enter  at  the 
positive  pole  (the  anode)  and  escape  at  the  negative  pole  (the  cathode). 
Now,  a  bullet,  when  shot  through  a  board,  tears  most  at  its  point  of  exit. 
We  ma}'  consider  the  negative  pole  as  that  which  tends  chiefly  to  stimulate 
the  ])arts  with  which  it  comes  in  contact  or  iipon  which  its  effects  are 
indirectly  exerted,  while  the  positive  pole  is  to  be  clinicall}'  regarded 
rather  as  the  sedative  pole,  in  contradistinction  from  the  negative.  The 
positive  pole  is  acid  in  its  reaction,  while  the  negative  is  alkaline. 

When  we  bear  the  essential  facts  of  electro-physics  in  mind,  man}' 


ELECTRO-THERAPEUTICS.  677 

of  tlie  difficulties  of  electric  measurement  are  more  clearly  appreciated,  as 
well  as  some  clinical  facts  that  are  indirectly  related  to  this  subject. 

To  accurately  determine  the  dose  of  electricit}'  which  the  patient  is 
taking,  several  factors  have  to  be  considei'ed  : — 

In  the  fii'st  place,  the  ninnber  of  mil  Hamper  es  (the  unit  of  current- 
strength  in  medicine)  may  he  measured  by  a  reliable  milliampere-meter. 

This  instrument  must  be  thrown  into  the  circuit, — i.e.,  between  the 
positive  pole  of  the  battery  and  its  negative  pole, — the  patient  being 
similarly  interposed  and  constituting  the  main  resistance  offered  to  the 
current  which  is  supposed  to  be  passing.  The  resistance  of  the  rheo- 
pliores  and  of  the  galvanometer  itself  must  be  added  to  that  of  the 
patient  in  determining  the  total  of  external  resistance  offered  to  the 
electric  current, — provided  the  electrodes  admit  of  a  circuit. 

The  importance  of  having  a  reliable  milliampere-meter  (if  any  is 
employed)  must  be  apparent  to  the  merest  tyro  in  electricit}'.  Unfor- 
tunately for  science,  the  market  is  flooded  to-day  with  clieap  instruments 
that  are  absolutely  worthless  for  scientific  purposes.  Many  of  them  are 
never  tested  individually  before  being  sold,  even  if  made  upon  scientific 
principles.  Others  fail  to  record  more  than  thirty  or  forty  milliampcres 
of  current,  and  on  that  account  are  not  adapted  for  use  when  very  high 
currents  are  employed,  even  if  deemed  reliable  as  far  as  they  go.  Con- 
siderable ingenuity  has  been  shown  of  late  in  the  attempts  of  profes- 
sional electricians  to  perfect  this  instrument,  the  iitility  of  Avhich  is 
becoming  more  generally  recognized  each  da}',  and  which  will  soon  con- 
stitute a  ver}'  important  part  of  each  electrician's  outfit.  Perhaps  one 
of  the  best  instruments  yet  introduced  to  the  profession  is  known  as  the 
"dead-beat"  milliampere-meter,  and  is  manufactured  b}' Messrs.  Waite 
and  Bartlett,  of  Xew  York. 

This  instrument  (Fig.  153)  is  so  called  because  the  oscillations  of  its 
needle  (which  in  most  galvanometers  amount  to  from  fifteen  to  sixty 
before  the  needle  comes  to  rest)  are  dampened  b}'  the  suspension  of  the 
needle  in  a  cylindrical  block  of  copper  by  means  of  a  fibre.  This  block 
becomes  electrified  by  an  induction  and  creates  an  opposing  current,  which 
reduces  the  oscillations  to  three  or  four  after  the  current  has  been  shut  off 
or  reversed.  B}-  means  of  two  shunt-coils  this  instrument  can  be  made  to 
accurately  record  as  high  as  five  hundred  milliamperes,  or  as  low  as  one- 
tenth  of  one  milliampere.  The  mirror  allows  the  operator  to  read  the 
needle-deflections  "with  as  much  ease  as  he  would  those  of  a  vertical 
galvanometer.  Rockwell,  in  a  late  pul)lication,  joins  with  me  in  the 
view  that  this  instrument  is  a  great  improvement  upon  any  other  hitherto 
at  our  command  for  the  measuring  of  current-strength. 

The  "absolute  galvanometer"  of  Hirschmann  is  another  desirable 
instrument,  but  it  is  too  expensive  for  general  use  in  the  profession. 


678  LECTURES   ON   NERVOUS   DISEASES. 

The  needle,  however,  rests  upon  two  points  which  are  liable  to  get  bent 
or  to  oxidiz-e. 

Respecting  the  employment  of  the  galvanometer  in  the  measure- 
ment of  galvanic  dosage,  M.  Yigouroux  has  lately  contributed  a  paper  to 
the  Biological  Society  of  Paris,  in  which  he  raises  a  point  not  generally 
considered,  viz.,  whether  the  electro-motive  force  which  propels  the  cur- 
rent through  the  external  resistance  aflbrded  by  the  galvanometer,  the 
rheophores,  and  the  tissues  of  the  patient  should  not  be  taken  into 
account  along  with  the  reading  of  the  galvanometer.  He  cites,  as  an 
example,  that  to  give  two  patients  a  current  of  five  milliamperes,  thirty- 
six  Daniell  elements  were  required  in.  one  and  only  twelve  in  the 
other.  Both  received  the  same  quantity;  but  one  received  it  under 
three  times  the  pressure  of  the  other.  In  any  given  case,  as  he  states, 
the  galvanometer  falls  to  show  this  point.  He  believes  that  currents  are 
modified  In  their  physiological  attributes  b^-  the  electro-motive  force  as 
well  as  by  the  quantity  and  density.  He  therefoi-e  suggests  that  the 
quantity'  as  shown  b^'  the  galvanometer  and  the  elctro-motlve  ibrce, 
which  Is  easll}'  ascertainable,  after  noting  the  number  and  the  character 
of  the  cells  emploj'ed,  be  alike  recorded  In  each  observation.  B\-  niultl- 
pl^'lng  the  electro-motive  force  by  the  quantity,  we  obtain  the  energy  of 
the  current  in  ''  volt-amperes  "  or  "  watts." 

Respecting  this  point,  this  observer  suggests  that  with  an  equal 
number  of  "  watts  "  a  current  of  great  intensity  and  feeble  electro- 
motive force  would  have  a  totally  ditferent  therapeutic  action  from  a 
current  inversel}-  constituted. 

He  employs  the  Depi-ez-d 'Arson val  galvanometer  with  a  vertical 
needle.  This  instrument  is  perfectly  astatic.  He  also  employs  a  special 
commutator,  which  is  so  arranged  as  to  place  at  will  tiie  galvanometer 
In  the  circuit  of  the  electrode  or  In  derivation.  It  Is  graduated  for  fiftj' 
volts. 

The  onl}'  criticism  that  I  would  make  to  the  views  of  this  observer 
is  that  possiblj'  the  resistance  In  the  rheophores,  the  electrodes,  etc., 
have  not  been  uniform  in  all  his  experiments.  Much  of  the  electro- 
motive force  may  have  been  expended  in  trying  to  overcome  an  imper- 
fect conduction  outside  of  the  tissues  of  the  patient.  In  that  case  the 
patient  would  not  receive  the  current  under  as  high  a  pressure  as  the 
electro-motive  force  of  the  battery  would  indicate. 

In  the  second  place,  mere  vieasurement  of  current-strength  by  the 
milliampere-meter  is  not  sufficioit  for  exact  and  scientific  electrical 
treatment  of  morbid  physical  conditions. 

If  an  experiment  be  made  with  a  fixed  number  of  cells  of  the  same 
pattern  and  freshly  filled,  by  [massing  the  current  through  animal  tissues 
with  electrodes  of  ditferent  sizes  placed  upon  identical  spots  of  the  same 


ELECTEO-THEKAPEUTICS.  679 

individual,  it  will  lie  found  that  the  milliampere-meter  will  record  a 
larger  number  of  niillianiperes  when  the  electrodes  are  large  than  when 
small,  and  that  the  smaller  the  electrodes  the  greater  will  be  the  dis- 
comfort to  the  patient,  in  spite  of  the  fact  that  the  amount  of  current  is 
less  than  when  the  electi'odes  are  increased  in  size. 

Now,  the  density  of  the  current  is  a  very  important  factor  in  electro- 
therapeutics, especially  so  after  the  current  has  reached  the  diseased 
poi'tion  of  the  body  which  we  wish  to  influence  by  it.  All  electrical 
currents  tend  to  diffuse  themselves  to  a  greater  or  less  extent  after  they 
enter  animal  tissues  :  hence,  if  the  diseased  part  is  deeply  situated  there 
is  of  necessity  more  diffusion  and  less  relative  density  than  if  the  part 
be  superficial,  and  therefore  nearer  to  the  electrode.  Zenner  puts  this 
point  in  a  late  lecture  very  clearly,  when  he  says,  "  The  density  is  in 
inverse  proportion  to  the  size  of  the  conductor  through  which  it  flows : 
therefore,  with  the  same  current-strength  it  is  greater  when  we  apply 
small,  less  wlien  we  appl}'  large,  electrodes.  When  the  area  of  disease  is 
near  the  surface  we  often  apply  small  electrodes  in  order  that  as  dense  a 
current  as  possible  should  enter  it ;  but  if  we  wish  to  att'ect  a  deep-seated 
part,  the  spinal  cord  for  example,  as  the  current  becomes  verj'  much 
diffused  before  reaching  it,  it  is  necessary  that  a  large  quantity  of  elec- 
tricity should  enter  the  bod^',  and  for  this  reason  we  applj'  lai'ge 
electrodes." 

We  have  already  noted  the  important  I'act  that  the  density  of  the 
current  affects  the  current-strength.  A  patient  will  feel  a  very  dense 
current  of  five  milliamperes  (administered  of  necessity  through  a  some- 
what small  electrode)  more  perhaps  than  one  of  twent}'  milliamperes 
entering  the  same  region  of  the  body  through  a  large  electrode. 

In  the  third  place,  some  basis  of  vieasurement  of  electrodes  must 
he  generally  accepted  by  the  profession  before  electrical  dosage  can  be 
considered  as  jilaced  upon  a  jyositively  scientific  basis. 

Erb  has  suggested  that  an  electrode  of  10  sq.  cm.  be  regarded  as  the 
normal  size.  Remak  has  proposed  that  a  series  of  graduated  electrodes 
of  10,  15,20,  etc.,  sq.  cm.  be  employed,  and  the  size  recorded  as  each 
application  is  made.  It  has  been  suggested  also  to  express  the  relation 
between  the  current-strength  and  the  electrode  by  making  the  milliam- 
peres the  numerator  and  the  size  of  the  electrode  in  square  centimetres 
the  denominator  of  a  fraction. 

By  such  a  system  of  record  the  results  of  treatment  in  the  hands  of 
different  observers  could  be  critically  analyzed.  Some  satisfactory 
deductions  relative  to  electro-therapeutics  might  possibly  be  then  estab- 
lished beyond  contradiction,  provided  that  due  care  be  taken  relative  to 
the  saturation  of  the  electrodes,  the  pressure  employed  upon  them,  the 
conduction  of  the  rheophores,  the  skin  of  the  patient,  etc. 


680  LECTURES   ON   NERVOUS   DISEASES. 

In  the  fourth  place,  it  is  very  important  that  the  placing  of  elec- 
trodes upon  the  cutaneous  or  mucous  surfaces  should  be  based  upon 
scientific  principles. 

Erb  has  shown,  in  some  diagrammatic  cuts  incorporated  in  his  hook, 
the  different  areas  of  diffusion  that  ensue  whenever  the  electrodes  are 
placed  near  together  or  wide  apart.  When  near  together  the  greatest 
densit}'  lies  almost  in  a  direct  line  between  the  electrodes,  especially 
when  applied  to  a  similar  surface  of  the  body.  When  we  wish  to  obtain 
the  greatest  possible  density  in  deeply  situated  parts,  or  when  the  special 
effects  of  either  pole  of  a  galvanic  battery  are  to  be  attained,  the  elec- 
trodes are  to  be  widely  separated. 

The  sternum  is  probably  the  best  point  upon  the  cutaneous  surface 
of  the  body,  in  the  vast  majority'  of  cases,  for  the  application  of  the  so- 
called  "neutral  electrode," — i.e.,  the  pole  wliose  effects  upon  the  diseased 
part  are  the  least  to  be  desired.  Another  point  commonl3'  used  for  this 
purpose  is  the  nape  of  the  neck.  This  point  is  most  easily  reached  on 
account  of  the  clothing,  but  it  is  too  abundantly  supplied  with  muscles 
to  be  as  desirable  as  the  sternum. 

A  wide  separation  of  the  electrodes  during  a  galvanic  application  is 
a  ver}'  important  point  to  insure  in  case  the  efl'ects  of  either  pole  upon 
some  special  part  are  particularly  to  be  desired.  Thus,  for  example, 
when  the  electrical  formuhe  of  individual  muscles  or  special  nerve-trunks 
are  being  tested  to  determine  if  the  "  reaction  of  degeneration  "  exists 
or  is  absent,  the  experiment  should  never  be  made  when  the  neutral  pole 
is  sufiiciently  near  to  the  active  pole  whose  effects  are  being  studied  to 
influence  the  reactions  obtained.  Again,  in  the  treatment  of  disease  we 
sometimes  wish  to  influence  the  diseased  part  exclusively  b}'  means  of  the 
anode  or  cathode.  In  such  a  case,  the  poles  of  the  battery  should  be 
as  widely  separated  as  possible. 

In  the  fifth  place,  the  conductivity  of  the  skin  to  electrical  currents 
is  modified  by  several  factors  which  must  be  carefully  co)isidered  in  every 
case. 

Among  these  the  saturation  of  the  electrodes,  the  employmeiit  of 
salt  in  the  saturating  solution,  and  the  amount  of  pjressure  exerted  upon 
the  electrodes  when  applied  to  the  skin  are  w^orthj'  of  special  mention. 
Patients  afllicted  with  dropsical  conditions  offer  a  less  resistance  than 
those  in  whom  the  tissues  are  normal. 

These  minor  details  are  not  to  be  ignored  by  those  who  endeaA'or  to 
do  scientific  electrical  work  in  the  treatment  of  disease  by  galvanism. 

If  you  wish  to  test  the  value  of  these  suggestions,  put  a  patient  and 
also  a  reliable  milliampere-meter  into  the  circuit  of  a  galvanic  batteiy. 
First,  use  dry  or  metallic  electrodes  and  note  the  current-strength  of  a 
definite  number  of  cells  when  they  are  applied  lightly  and  also  firmh*  to 


ELECTRO-THERAPEUTICS.  681 

the  skin.  Then  cover  the  electrodes  with  absorbent  cotton  and  wet  them 
thoroughly  in  plain  water,  noting,  after  so  doing,  the  results  shown  by 
the  galvanometer  of  light  and  firm  pressure.  Finally,  add  a  tetispooni'ul 
of  table-salt  to  the  water  and  again  thoroughl}'  wet  the  electrodes  and 
the  skin  of  the  patient  with  this  saline  solution,  noting  for  the  third  time 
the  current-strength  obtained  by  a  light  and  firm  application  of  the  elec- 
trodes. In  each  experiment  be  sure  that  the  battery  has  the  same  number 
of  cells  in  action  and  that  polarization  has  not  been  allowed  to  occur. 
Tiiis  can  be  insured  in  most  batteries  by  raising  the  elements  from  the 
fluid  while  the  cells  are  not  in  use. 

The  effect  of  firm  pressure  upon  the  electrodes  and  the  use  of  salt 
is  to  lessen  the  resistance;  hence,  the  current-strength  is  often  height- 
ened by  so  doing.  It  has  been  wisel}^  suggested  that  the  handle  of  elec- 
trodes be  furnished  with  a  spring  gauge  which  will  enable  the  observer 
to  know  positively  that  the  pressure  exerted  upon  the  electrodes  in  any 
given  ease  is  uniform  at  each  sitting. 

In  the  sixth  jjlace,  the  employment  of  a  good  rheoi^tat  in  galvanic 
applications  is  very  advantageous  and  oftentimes  almost  indispensable. 

The  conductivity  of  the  skin  varies  in  the  same  individual  with  the 
condition  of  the  surface.  When  wet,  as  for  example  with  perspiration, 
or  somewhat  dampened  by  a  humid  atmospliere,  it  is  better  tlian  when 
dr}'  or  parched.  This  tends  to  explain  in  many  cases  why  i)atients  feel 
a  galvanic  application  of  a  definite  number  of  cells  more  at  some  times 
than  at  others.  The  milliampere-meter  will,  when  employed, always  show 
the  reason  of  this. 

Again,  it  is  often  necessary  for  scientific  record  to  determine  the 
exact  resistance  which  any  part  offers  to  the  passage  of  a  galvanic  cur- 
rent. This  can  be  accurately  measured  by  a  coil  rheostat.  For  example, 
the  tissues  of  a  patient  may  cause  a  deflection  of  the  needle  of  a  galva- 
nometer, placed  in  the  same  circuit  as  the  patient,  of  twenty  milliamperes 
with  thirty  freshly  filled  Grenet's  cells.  Now  drop  the  patient  from  the 
circuit  and  place  a  coil  rheostat  in  his  stead,  adding  sufficient  resistance 
by  means  of  shunts  in  the  rheostat  to  bring  tlie  needle-defiection  to 
exactly  twent,y  milliamperes.  The  resistance  indicated  in  the  rheostat 
marks  the  resistance  of  the  tissues  of  the  patient,  the  rheophores,  and  the 
electrodes,  which  were  traversed  by  the  galvanic  circuit  when  the  needle- 
deflection  was  first  noted. 

In  the  cabinet  battery  which  I  have  devised  for  the  use  of  ph3'sicians 
(Fig.  16'2)  I  have  lately  incorporated  a  reliable  coil  rheostat,  which  may  be 
connected  or  disconnected  at  the  will  of  the  operator  by  means  of  a  switch. 
This  I  regard  as  a  most  valuable  improvement  upon  the  original  model. 

The  rheostat  enables  us,  furthermore,  to  gradually  increase  or 
decrease  the  current-strength  without  a  danger  of  breaking  the  current 


682  LECTURES  ON  NERVOUS  DISEASES. 

(an  accident  not  without  dan2:er  when  verj'  high  currents  are  being 
employed).  AVe  do  not  have  to  toucli  the  batteiy  when  this  instrument 
is  employed,  but  simply  turn  on  its  full  capacity  and  graduate  its 
strength  by  the  rheostat  alone.  Many  modifications  of  the  liuid  rlieostat 
have  been  made  with  the  view  of  removing  the  manj^  objectionable 
features  of  this  instruraeut.  I  have  for  some  years  personally'  discarded 
fluid  rheostats  in  my  practice  because  of  the  repeated  annoyances  they 
have  caused  aud  the  uncertainties  which  attend  their  use. 

I  must  confess  that  on  reading  the  description  of  various  instruments 
I  fail  to  see  any  practical  advantage  to  be  gained  by  their  use  over  a  well- 
constructed  coil  rheostat.  Yet,  on  the  other  hand,  there  is  without 
doubt  a  field  for  a  perfect  fluid  rheostat.  They  are  cheaper  to  construct ; 
thej'  are  somewhat  easier  for  a  novice  to  manage ;  thej'  can  be  trans- 
ported with  little  additional  weight  or  inconvenience;  and  they  mate- 
rially aid  an  operator  in  graduating  the  current  without  danger  of  sud- 
denly breaking  it  while  the  application  is  being  made. 

A  physician  in  general  practice  wants  an  apparatus  that  is  light,  not 
too  bulky  to  transport  easily,  and  one  that  is  reliable  under  all  conditions. 
This  is  the  great  desideratum,  and,  unfortunateh',  less  easily-  furnished 
than  desired.  A  reliable  milliampere-meter,  a  serviceable  fluid  rheostat, 
and  a  good  galvanic  battery  are  perhaps  the  three  most  important  parts 
of  an  electrician's  outfit  for  general  use  at  the  homes  of  his  patients. 

The  general  practitioner  is  apt  to  become  easily  confused  by  a  super- 
abundance of  switches,  plugs,  and  other  electi'ical  devices.  He  wants  his 
electrical  outfit  as  simple  and  inexpensive  as  it  can  be  made  without 
sacrificing  delicacy,  reliability,  and  durability  in  any  part  of  his  apparatus. 
If  he  strives  for  scientific  attainments  he  will  sooner  or  later  be  able  to 
judge  himself  of  the  defects  of  his  outfit,  and  supply  the  wants  with 
greater  discretion  than  when  he  originally  purchased  it. 

At  the  present  time,  gynecologists  are  testing  very  extensively  the 
method  first  advocated  by  Apostoli  for  the  treatment  of  uterine  fibroids 
in  which  currents  of  from  one  hundred  milliamperes  upward  are  being 
frequentl}'  employed.    • 

The  question  of  galvanic  dosage  has  been  brought  prominently  for- 
ward in  a  controversial  conflict  between  some  of  the  advocates  of  this 
method  and  electricians  during  the  past  year;  some  of  its  adherents 
being  accused  of  serious  errors  in  the  computation  of  the  actual  currents 
which  have  been  employed  in  this  therapeutic  procedure. 

The  whole  controversy,  to  my  mind,  seems  to  turn  upon  two  factors 
which  do  not  appear  to  be  fully  decided.  Tliese  are:  (1)  the  internal 
resistance  of  the  batteries  employed  to  generate  the  current ;  and  (2)  the 
external  resistance  which  tlie  rheophores,  the  galvanometer,  and  the 
animal  tissues  traversed  by  the  circuit  together  help  to  constitute. 


ELECTKO-THEKAPEUTICS.  6C3 

Now,  the  emplo3'ment  of  a  coil  rheostat  will  enable  any  one  to 
determine  the  exact  resistance  ollered  hj  the  tissues  in  each  individual 
case  with  little  loss  of  time  or  labor. 

The  external  resistance  to  the  passage  of  a  galvanic  circuit  is  a  verj' 
important  factor  in  modifying  the  current-strength  which  the  milliain- 
pere-meter  indicates.  To  repeat  what  has  already  been  said,  there  are 
only  three  factors  in  Ohm's  law,  any  one  of  which  can  be  easily  figured 
when  the  other  two  are  known.  Ohm's  law  is  as  follows :  The  electro- 
motive force  divided  hy  the  resistance  equals  the  current-strength.  The 
electro-motive  force  (E)  is  estimated  in  volts;  the  resistance  (11)  in  ohms; 
and  the  current  (C)  in  artijyeres.  To  put  this  in  a  mathematical  form,  the 
following  equations  are  applicable  to  the  solution  of  any  such  problem  : — 

E  E 

C  =  —  orE  =  CXI^o^^  =  — 
R  C 

Finally^  in  the  seventh  place,  the  length  of  the  sitting  is  a  factor  in 
electrical  dosage. 

This  factor  must,  unfortunately,  remain — for  some  time  at  least — 
a  matter  of  pure  empiricism.  As  a  general  rule,  the  weaker  the  current 
the  longer  may  its  application  be  prolonged.  Still  there  are,  without 
question,  certain  individuals  who  are  more  tolerant  of  electrical  currents 
than  others  ;  and  the  phj^sical  conditions  of  each  patient  have  to  be  taken 
into  consideration  before  the  duration  of  a  seance  can  be  decided  upon. 
Of  necessit}',  the  experience  and  judgment  of  the  operator  will  always 
prove  of  material  service  in  deciding  such  questions  as  they  arise ;  and 
it  is  here  that  the  success  of  some  and  the  lack  of  success  of  others  may 
possibly  lie. 

The  tendency  of  the  age  is  toward  the  use  of  much  stronger  currents 
than  were  formerly  considered  judicious  by  the  German  investigatoi'S. 
Especially  is  this  true  in  the  treatment  of  some  of  the  graver  diseases, 
and  in  many  conditions  where  electrolysis  and  the  galvano-cautery  are 
now  successfully  emploj^ed. 

In  concluding  my  remarks  concerning  galvanic  dosage,  I  trust  the 
many  aspects  of  the  question  may  now  be  more  clearly  understood  by 
some  of  my  readers  ;  and  that  the  necessity  of  a  more  complete  electrical 
outfit  than  many  general  practitioners  now  possess  may  be  ai)parent  to 
them.  These  remarks  apply  only  to  galvanic  currents,  and  not  to 
faradaic  or  static  apjilications. 

We  have  now  discussed  the  essential  points  pertaining  to  electro- 
physics  and  electro-diagnosis,  and  there  remains  now  for  us  to  consider 
the  uses  of  electricity  in  the  treatment  of  diseased  conditions  of  various 
organs  and  tissues. 

Before  we  pass  to  details  of  the  practical  part  it  may  be  well  for  us 


684  LECTURES   ON  NERVOUS   DISEASES. 

to  review  in  a  general  way  some  of  the  laws  wliich  sliould  govern  us  in 
applying  electric  currents  to  tlie  different  tissues,  and  tlie  objects  to  be 
attained  by  the  emplo^'ineut  of  faradaism,  galvauisni,  and  static  electricity. 

GENERAL   ELECTKO-THERAPEUTICS. 

The  rapidity  and  completeness  of  rei)()ited  cures  of  nervous  affec- 
tions by  the  use  of  electric  currents  upon  living  tissues  during  the 
last  quarter  of  a  century  leave  no  room  for  doul)t  tiiat  tliis  agent  is 
particularly  valuable  in  the  treatment  of  paral3^sis,  neuralgia,  spasmodic 
diseases,  disturbances  in  the  sensibilit,y  of  the  skin,  and  many  disordered 
states  of  the  brain,  spinal  cord,  and  peripheral  nerves  themselves.  We 
have  undisputed  facts  which  i)rove  also  that  blood  ma^y  be  coagulated 
with  safety  within  some  aneurismal  sacs  by  the  galvanic  current,  that 
the  life  of  the  ovum  may  be  destroyed  in  extra-uterine  i)regnancy,  that 
animal  tissues  may  be  disintegrated  by  chemical  changes  induced  within 
them  by  this  agent,  and  that  neoplasms  may  be  removed  without  hemor- 
rhage by  the  cautery  loop. 

Our  present  ignorance  of  the  molecular  and  nutritive  changes  in 
tissues  (as  the  cause  or  result  of  disease)  renders  it  impossible  to  do 
more  than  speculate  upon  the  theory  of  the  therapeutical  action  of  elec- 
tricity in  man}'  cases  ;  but,  on  the  other  hand,  our  empirical  knowledge 
of  these  eflects  is  none  the  less  valuable  because  we  are  unable  to  explain 
them.  The  same  criticisms  would  otherwise  hold  good  in  reference  to 
almost  all  of  the  drugs  employed  in  medicine.  None  of  us  know  exactly 
how  they  produce  their  specilic  effects. 

Concerning  speculation  upon  electrical  effects  on  living  tissues, 
Erb  remarks  as  follows  :  "  What  api)ears  more  natural  than  that  neu- 
ralgia and  spasms  could  be  relieved  by  the  sedative  action  of  the 
anode,  with  production  of  anelectrotonus,  and  that  anesthesia  and 
paralysis  could  be  cured  by  the  exciting  action  of  the  cathode,  with 
production  of  catelectrotonus?  But,  apart  from  the  fact  that  we  are 
not  certain  that  an  increase  of  irritability  really  occurs  in  one  group 
of  cases  and  a  diminution  in  the  other,  it  must  be  remembered  that 
electrotonic  action  disappears  very  rapidly  after  the  cessation  of  the 
current,  while  the  curative  effects  of  the  current  are  more  or  less 
permanent." 

Now,  we  may  summarize  the  general  principles  which  regulate  the 
use  of  electric  currents  as  follows  : — 

(1)  They  ma}'^  exert,  under  certain  circumstances,  a  stimnlating  or 
irritating  effect.  This  is,  perhaps,  the  basis  of  the  most  varied  applica- 
tions of  electricity  to  disease. 

(2)  They  may  exert,  when  properly  applied,  a  sedative  action  on 
nerves  or  nerve-centres. 


GENERAL  ELECTEO-THERAPEUTICS  685 

(3)  The}'  may  be  made  to  exert  a  catalytic  action  upon  neoplasms, 
enlarged  glands,  etc, 

(4)  They  are  capable  of  causing  electrolysis.  This  action  is  one 
which  has  lately  come  into  prominence. 

(5)  They  create  heat  under  certain  conditions.  The  galvano-cautery 
is  to-day  assuming  a  very  prominent  place  in  some  of  the  departments 
of  surgery. 

Let  us  now  discuss  each  of  these  special  actions  separately,  noting 
the  general  points  of  interest  pertaining  to  each  which  will  aid  us  in 
properly  treating  our  patients.  Electrolysis  and  the  galvano-cauterj'' 
have  been  treated  of  in  previous  pages. 

Stimulating  or  Irritating  Effect  of  Electricity. — This  is  indi- 
cated in  many  diseased  conditions  encountered  by  the  neurologists  as 
well  as  by  the  general  practitioner.  Among  these  the  following  ma}^  be 
prominently  mentioned  : — 

Some  of  the  various  forms  of  cerebral  and  spinal  diseases. 

Depressed  irritability  of  some  special  nerve-trunks. 

Abnormal  resistance  to  conduction  of  electric  currents,  exhibited  by 
the  motor  or  sensory  nerve-filaments  of  some  part. 

As  a  counter-irritant  to  some  pathological  conditions. 

Trophic  disturbances  of  special  regions  (skin,  nails,  hair,  etc.). 

Vaso-motor  depression. 

Atrophic  changes  in  muscles. 

As  a  means  of  indirectly  affecting  the  nerve-centres  through  the 
sensory  nerves,  thus  influencing  respiration,  circulation,  phonation, 
vaso-motor  paths,  peripheral  organs,  the  muscles,  etc. 

The  methods  of  application  which  are  best  adapted  to  accomplish 
irritating  or  stimulating  effects  are  differently  stated  by  authors.  Per- 
sonally, I  do  not  confine  myself  exclusively  to  faradaism  or  galvanism. 

The  faradaic  current  is  more  commonly  employed  for  this  purpose 
than  the  galvanic.  The  electrodes  should  be  selected,  as  to  their  size 
and  shape,  in  accordance  with  the  parts  to  be  acted  upon  ;  they  should 
])e  well  moistened  with  salt  water,  and  kept  closely  in  contact  with  the 
skin.  The  wire  l)rush  is  the  best  electrode  to  stimulate  the  nerves  or 
other  tissues  of  the  skin.  It  should  be  used  dry.  I  prefer  the  secondary 
faradaic  current  to  that  of  the  primary  coil  for  stimulating  effects. 

If  galvanism  is  employed  as  a  stimulant,  Remakes  plan.,  of  moving 
the  well-moistened  cathode  rapidly  over  the  nerve-trunk  or  muscle  to  be 
stimulated,  with  a  current  sufiiciently  strong  to  cause  strong  waAC-like 
contractions,  is  a  good  one.  Another  method,  termed  by  triiis  author 
'■'terminal  labile  sliintdation,^''  consists  in  stroking  the  tendinous  end 
of  a  muscle  with  tiie  cathode  so  as  to  affect  the  entire  length  of  the 
muscle.     In  both  of  these  methods,  the  anode  is  kept  stationary  upon 


686  LECTURES   ON  NERVOUS   DISEASES. 

some  indifferent  or  neutral  point — the  centre  of  the  sternum  by  preference, 
or  the  nape  of  tlie  neci<. 

One  of  the  most  vigorous  methods  of  stimulation  consists  in  rapidly 
changing  the  polarity  by  means  of  a  commutator,  when  the  galvanic 
batter V  is  employed. 

The  Combined  Current. — Another  method  which  I  employ  (not 
generally  mentioned  in  text-books)  consists  in  connecting  a  galvanic 
battery,  by  means  of  a  rheophore,  witli  a  faradaic  instrument,  thus 
bringing  both  a  constant  and  induced  current  to  bear  upon  the  tissues  at 
once.  The  rheopliore  which  connects  the  batteries  joins  the  positiA-e 
binding-post  of  tlie  galvanic  instrument  with  the  secondary  coil  of  the 
faradaic ;  the  two  rheophores  connected  with  the  electrodes  run  from  the 
negative  binding-post  of  the  galvanic  and  from  the  secondarj"  coil  of  the 
faradaic  instrument.  The  two  instruments  (faradaic  and  galvanic)  are 
thrown  into  action  simultaneously,  and  the  strength  of  the  current  em- 
ployed is  graduated  by  the  number  of  cells  used  in  the  galvanic  battery 
and  b}^  the  extent  of  the  overlap  of  the  secondary  coil  of  the  faradaic 
instrument.  I  have  obtained  some  remarkable  results  by  the  stimulation 
thus  produced  in  various  forms  of  trophic  disturbances  of  the  skin  and 
muscles. 

The  stimulation  of  nerve-fibres  (when  obstacles  exist  to  their  con- 
duction) should  be  performed  peripherally  fi'om  the  site  of  the  lesion  in 
sensory  nerves,  and  as  centrally  as  possible  in  motor  nerves  (Erb). 
Degenerated  and  atrophied  nerves  and  muscles  require  a  direct  effect  of 
the  currents  employed.  For  these  reasons,  the  site  of  stimulating  elec- 
trical applications  depends  upon  the  situation  and  character  of  the  lesion 
and  the  object  to  be  attained. 

Modifying  Effects  of  Electric  Currents. — The  irritability  of  nerves 
and  muscles  may  be  influenced  by  electric  currents. 

In  certain  diseased  conditions,  we  may  expect  a  favorable  result  from 
such  an  action.  Thus,  for  example,  in  some  types  of  paralysis,  in  anaes- 
thesia, in  certain  vaso-motor  disturbances,  and  in  depressed  states  of 
cerebral  and  spinal  activity,  the  irritability  of  nerves  or  of  muscular 
fibres  is  diminished ;  hence  we  resort  to  the  so-called  "  catelectrotonic 
action  "  of  electricit}^  as  a  means  of  stimulating  and  restoring  the  normal 
irritability'  of  the  tissues  affected. 

It  is  now  generall}' accepted  as  proved  that  feeble  faradaic  currents 
will  accomplish  this  end.  Galvanic  currents,  when  applied  for  this  pur- 
pose, give  more  positive  results,  however,  than  faradaic. 

In  orfler  to  increase  irritability  by  galvanism,  the  negative  electrode 
should  be  ap]:»lied  in  a  stabile  manner  {i.e..  without  being  moved)  to  the 
part  upon  wliich  this  effect  is  to  be  produced  ;  and  the  strength  and 
duration  of  the  current  should  be  steadily  increased.     When  the  muscles 


GENERAL   ELECTRO-THERAPEUTICS.  687 

or  motor  nerves  have  been  exhausted  b}-  over-exertion,  excessive  fatigue, 
etc.,  this  action  (termed  by  Heidenhain  the  "  refreshing  action  "  of 
galvanism)  is  particularly  indicated. 

Those  conditions  in  which  the  normal  irritahiUtij  of  nerves  or 
muscles  is  intensified  demand  the  so-called  "  anelectrotonic  action  "  of 
electricity.  These  conditions  comprise  all  irritative  states  of  the  sensor}-, 
motor,  and  vaso-motor  tracts  within  or  without  the  brain  and  spinal  cord  ; 
lience,  we  employ  this  action  in  neuralgias,  spasmodic  affections,  hyperaes- 
thesia  of  any  of  the  cerebro-spinal  nerves,  headache,  excitation  of  any 
of  the  special  senses,  cerebral  and  spinal  irritation,  etc. 

In  order  to  decrease  the  irritability  of  nerves  or  muscles,  we  may 
employ  very  powerful  faradaic  currents.  We  may  also  begin  by  em- 
plo3'ing  a  feeble  faradaic  current  and  gradually  increasing  its  strength  to 
the  highest  point  of  endurance ;  then  maintaining  it  at  this  point  for 
some  time ;  and  subsequentl}^  reducing  it  graduallj'  to  the  feeblest  cur- 
rent perceptible  to  the  patient.  This  method  is  known  as  the  "  increasing 
induction  method.''''  Electrodes,  well  moistened  and  of  large  size,  should 
be  employed  and  kept  immovable  upon  tlie  same  points  during  the  appli- 
cation. It  is  often  advisable  to  repeat  this  procedure  several  times  at 
one  sitting  (Erb). 

When  the  galvanic  current  is  employed  for  the  purpose  of  decreasing 
irritability,  the  positive  pole  is  made  fast  at  the  point  to  be  intlnenced. 
The  current  is  increased  in  strength  and  maintained  at  its  maxinnim  for 
some  time,  after  which  it  should  be  decreased  gradually  until  it  cannot  be 
perceived  by  the  patient.  The  gradual  decrease  of  tlie  current-strengtii 
prevents  the  marked  temporary  increase  of  irritability  which  is  liable  to 
follow  this  method  when  this  step  is  omitted. 

Static  electricity  exerts  in  many  cases  an  immediate  beneficial  effect 
upon  neuralgic  pains  (especially  upon  sciatica)  and  upon  the  various 
spasmodic  affections,  as,  for  example,  chorea,  paraljsis  agitans,  tremor, 
contractui-e,  etc.  These  effects  are  obtained,  in  some  cases,  when  gal- 
vanism and  faradaism  have  proved  of  no  benefit.  I  should  never  regard  a 
case  as  incapable  of  benefit  by  electric  treatment  until  static  electricity, 
in  the  form  of  insulation,  the  electric  wind,  or  the  spark,  had  been 
thoroughly  tested.  I  have  had  better  results  with  this  form  of  current 
in  tremor  than  with  galvanism  or  faradaism. 

Some  forms  of  pain  (as,  for  example,  the  pains  of  ataxia,  sciatica, 
trigeminal  neuralgia,  muscular  rheumatism,  etc.)  are  oftentimes  relieved 
b}'  a  few  applications  of  static  electricit}-.  My  experience  with  this 
agent  has  convinced  me  that  its  effects  ai'e  often  satisfactory  in 
cases  where  pain  is  a  prominent  symptom,  when  galvanism  has  been 
tried  without  benefit.  I  have  found  that  insulation  and  the  ab- 
straction of  heavy  sparks  from  the  seat  of  pain  give  the  best  results. 


688  LECTURES   ON   NERVOUS   DISEASES. 

This  therapeutical  agent  will  be  discussed  separately,  later  in  this 
volume. 

Catalytic  Action  of  Electrical  Currents. — Under  this  heading 
we  include  (1)  an  increase  of  absorption  produced  by  dilatation  of  the 
capillary  bh>od-vessels  and  lymphatics  ;  (2)  an  increased  capabilit}'  of 
tissues  for  imbibition  of  fluids,  through  an  increase  of  osmotic  processes  ; 
(3)  changes  in  the  disassirailation  and  nutrition  of  nerves,  on  account  of 
their  stimulation  or  refreshing  effects;  (4)  changes  in  the  molecular 
arrangement  of  tissues,  caused  by  electrolytic  processes  ;  and  (5)  the 
results  of  the  transportation  of  fluids  from  one  pole  to  the  other  (Remak 
and  Erb). 

Remak  has  shown  that  muscles  become  congested  and  greatly 
swollen  when  subjected  to  galvanism.  They  are  rendered  tense,  and 
(according  to  this  observer)  absorb  water  more  freely  than  muscle  Avhich 
has  not  been  galvanized. 

Changes  of  a  marked  character  ma}^  he  induced  in  the  skin  by  gal- 
vanism.    These  have  been  studied  by  Erb,  Remak,  Bollinger,  and  others. 

The  vaso-motor  nerves  may  be  influenced  b}'^  electrical  currents. 
This  is  shown  by  many  of  the  later  investigations, — prominently  those 
of  Lowenfeld,  which  apparently  demonstrate  that  contraction  and 
dilatation  of  the  vessels  of  the  brain  result,  respectively,  from  antero- 
posterior and  transverse  currents  through  the  head  from  a  galvanic 
battery. 

Although  we  are,  as  yet,  unable  to  speak  with  positiveness  regarding 
the  certainty  of  the  catalytic  effects  of  electrical  currents,  or  to  map  out 
the  forms  of  disease  which  are  to  be  regarded  as  specially  indicating 
these  cataljtic  effects,  still  it  niay  be  said  that  the  following  states  have 
been  successfull}'  treated  by  electrical  currents,  and  that  the  cures  are 
probablj^  to  be  attributed  to  a  catalytic  action.  (1)  inflammatory  affec- 
tions of  the  nervous  system,  including  sclerosis,  myelitis,  neuritis,  etc. ; 
(2)  arthritis  and  chronic  exudations  into  joints  ;  (3)  glandular  enlarge- 
ments ;  (4)  hard  cicatrices,  periosteal  swellings,  and  fibrous  adhesions ; 
(5)  contusions,  sprains,  extravasations  of  blood,  and  other  results  of 
traumatisms. 

The  galvanic  current  is  the  one  that  is  generally  emplo^-ed  when 
catalytic  effects  are  desired.  In  diseased  conditions  of  the  brain,  spinal 
cord,  or  any  of  the  deeply  seated  organs,  the  faradaic  currents  are  not 
usually  productive  of  benefit. 

The  "  stabile  method  "  of  application  of  the  galvanic  current  is 
preferable,  to  \\\y  mind,  when  catalytic  action  is  to  be  attained.  The 
strength  of  the  current  should  be  sufl^cient  to  easily  overcome  the 
resistance  offered,  and  the  duration  should  be  sutficientlj'  prolonged  to 
accomplish  changes  in  the  tissues  subjected  to  its  influence.     One  j^ole 


GENERAL   ELECTEO-THEEAPEUTICS.  689 

is  placed,  as  a  rule,  at  an  indifferent  point  (the  sternum  by  preference), 
and  the  otiier  over  the  tissue  diseased.     Sometimes,  as  in  tlie  case  of  the 
brain,  for  example,  the  poles  are  placed  upon  either  side  of  the  diseased 
part.     Although  there  are  exceptions  to  the  rule,  it  is  well  to  use  the       • 
anode  or  positive  pole  over  the  diseased  part  when  pain  is  present,  when      / 
symptoms  of  active  irritation  exist,  or  when  the  morbid  processes  are    , 
verj'-  active.     The  cathode  or  negative  pole  is  best  adapted  to  influence 
chronic  morbid  processes,  such  as  sclerosis,  indurations,  etc.     Erb  recom- 
mends that  the  polarity  of  the  current  be  changed  several  times  in  either 
case ;  he  doubts  the  infallibility-  of  the  rule  given,  although  it  is  theoreti- 
cally sound.     Chvostek  urges  the  use  of  short  and  moderate  currents 
for  a  few  minutes  (three  to  ten)  when  catalytic  action  is  desired.     In 
this   way,   he   believes,  the  vaso-motor   and    trophic    nerves   are   more 
impressed  than  by  any  other  method. 

Respecting  the  catalytic  action  of  faradaic  currents,  a  diflTerence 
of  opinion  exists  between  authors  of  note.  One  thing  is  certain,  viz., 
that  strong  currents  are  required,  and  that  the  currents  must  be  passed 
directly  through  the  diseased  part  to  accomplish  marked  results. 
Glandular  tumors  have  been  resolved  by  this  method  with  great  rapidity 
in  some  recorded  instances. 

Galvanization  of  the  Cervical  Sympathetic. — This  method  has 
afforded  relief,  according  to  published  cases,  in  vaso-motor  and  trophic 
disturljances  of  the  nerve-centres,  the  e3'e,  viscera,  muscles,  joints,  and 
skin.  Thus,  for  example,  cases  of  cure  of  epilepsy,  atroph}'  of  the  optic 
nerve,  Basedow's  disease,  progressive  muscular  atrophy,  lead-palsy, 
scleroderma,  chronic  rheumatic  arthritis,  bulbar  parahsis,  neuralgias  of 
various  types,  and  many  other  conditions  have  been  reported  by  means 
of  this  method.  Respecting  this  step,  Erb  wisel}'  remarks  as  follows  : 
"  There  can  probably  be  no  doubt  of  the  correctness  of  a  part  of  these 
observations,  but  this  does  not  b}'  any  means  inipl}'  that  the  cervical 
sympathetic  is  responsible  for  such  results." 

When  we  review  the  structures  which  compose  the  neck  and  recall 
the  numerous  connections  which  exist  between  the  sympathetic  cords, 
the  pneumogastric  nerve,  the  brain  and  cervical  segments  of  the  cord, 
the  medulla  oblongata,  the  brachial  and  cervical  plexuses  of  nerves,  etc., 
it  becomes  clear  wiiy  De  Watteville  applies  the  term  "  sub-aural  galvan- 
ization "  and  Erb  the  term  "  galvanization  of  the  neck  ''  to  this  special 
procedure. 

The  steps  required  to  influence  these  parts  by  Meyer's  method  con- 
sist in  the  application  of  a  small  electrode  (cathode)  under  the  angle  of 
the  jaw  and  adjacent  to  the  hyoid  l)one,  and  then  crowding  it  backward 
and  upward  against  the  A'ertebral  column,  the  positive  electrode  (of 
larger  size)  being  placed  over  the  seventh  cervical  spine.     The  current 

44 


690  LECTURES   ON   NERVOUS   DISEASES. 

may  l>e  stabile.  lal)ile,  or  interrupted;  or  the  polarity  may  be  changed 
from  time  to  time  durini^  the  sitting  of  from  one  to  three  minutes.  Six 
to  ten  galvanic  cells  of  the  Grenet  variety  are  sufficient.  The  application 
may  be  unilateral  or  bilateral,  according  to  the  demands  of  the  case. 

Corning  has  devised  an  instrument  which  insures  carotid  compres- 
sion with  galvanization  of  the  neck  for  the  treatment  of  cerebral 
h3'per{iemia  and  some  other  morbid  conditions. 

Benedict  places  the  positive  pole  in  the  jugular  fossa,  and  the 
negative  pole  upon  tiie  superior  cervical  ganglion. 

General  Faradization. — This  method  of  administering  electricity- 
was  first  employed  by  Beard  and  Rockwell.  By  this  procedure  the 
entire  body  is  subjected  to  secondary  faradaic  currents  of  varying  inten- 
sity. It  is  applicable  chiefly  to  those  forms  of  nervous  disturbance  which 
are  associated  with  general  debility,  poverty  of  the  blood,  special 
diatheses  and  cachexia,  hysterical  atfections,  skin  diseases,  persistent 
chronic  inflammations,  and  other  results  of  low  vitality  or  functional 
derangements  of  the  organs.  ^^ 

To  apply  this  method,  the  patient  must  be  undressed  oxvery  loosely 
clothed.  The  feet  are  immersed  in  a  bowl  of  tepid  water  with  a  little 
salt  added,  in  which  the  cathode  is  also  placed  after  being  connected  by 
means  of  a  rheophore  to  the  binding-post  of  the  secondary  coil  of  a  fara- 
daic machine.  The  anode  is  held  in  one  hand  of  the  physician,  and  his 
other  hand  (well  moistened  in  salt  water)  is  applied  to  all  parts  of  the 
surface  of  the  patient's  body.  If  the  subject  can  bear  it,  a  large  electrode 
covered  with  absorbent  cotton  and  flannel,  or  with  a  soft  sponge,  is 
employed  in  place  of  the  hand.  The  application  should  begin  at  the 
head  and  terminate  at  the  feet,  the  strength  of  the  current  being  modi- 
fied from  time  to  time  as  the  feelings  of  the  patient  may  demand.  The 
extremities  and  back  should  have  vigorous  stimulation,  the  nerves  of  the 
neck  should  be  influenced  b}'  a  much  weaker  current,  and  the  coeliac 
plexus  should  be  influenced  by  a  stabile  application  of  a  few  minutes  over 
the  epigastrium.  The  entire  duration  of  the  application  occupies  from 
ten  to  twentj'-five  minutes.  It  may  be  applied  as  often  as  three  times  a 
week  if  necessaiy. 

Personallj',  I  can  attest  the  efficacy  of  this  treatment  as  a  general 
tonic.  I  have  witnessed  immediate  effects  from  it  in  some  of  m3'  cases, 
and  I  emploj"  it  constantly  in  a  modified  form. 

In  case  the  hand  of  the  attendant  is  to  be  employed  as  an  electrode, 
I  would  advise  the  use  of  an  instrument  which  I  have  devised  as  an 
improvement  over  the  waj'  originally  described  by  the  inventors  of  this 
method.  It  is  called  the  electric  bracelet.  It  is  placed  upon  the  right 
wrist  of  the  attendant  over  a  pad  of  wet  absorbent  cotton,  and  the  rheo- 
phore is  screwed  into  the  binding-post  upon  it.     The  right  hand  is  then 


GENERAL    ELECTRO-THERAPEUTICS.  G91 

•wet  in  salt-water  and  used  as  jn-eviously  described.  By  tliis  instrument 
the  hand  of  the  attendant  is  alone  subjected  to  the  current,  and  the 
fingers  can  detect  muscular  contraction  in  the  patient  even  Avhen  too 
feeble  to  be  seen  easily.  As  an  adjunct  to  massage,  I  employ  this  useful 
instrument  with  decided  benefit. 

General  Galvanization. — The  steps  required  by  this  method  are 
similar  to  those  previousl}'  described,  except  that  the  constant-current 
battery  is  employed  in  place  of  a  faradaic  machine. 

Central  Galvanization, — The  cathode  is  placed  over  the  epigas-  j 
trium.  This  electrode  should  be  of  large  size.  The  anode  is  stroked 
over  the  forehead,  with  a  current  of  about  two  milliamperes,  for  two 
minutes  ;  then  made  stabile  over  the  cranium  for  about  two  minutes ; 
then  moved  up  and  down  the  neck  on  each  side  for  the  same  duration  ; 
finally  it  should  be  moved  along  the  length  of  the  spine  for  about  five 
minutes.  This  method  was  a  favorite  one  with  the  late  Dr.  Beard,  who 
reported  cures  of  gastralgia,  h3'steria,  hypochondriasis,  nervous  dys- 
pepsia, and  many  of  the  symptoms  of  cerebral  and  spinal  neurasthenia 
by  its  continued  use.  In  two  cases  of  gastralgia  in  which  I  personally 
employed  it  for  some  time  I  obtained  an  absolute  recovery. 

The  Electrical  Bath. — This  method  of  administration  of  electricitj' 
to  a  patient  may  be  accomplished  by  using  a  metal  tub,  or  one  which  is 
composed  of  a  non-conductor.  If  a  metal  tub  is  emplo^'ed,  the  patient 
must  be  protected  from  actual  contact  with  it.  This  is  usually  accom- 
plished by  means  of  wooden  slats  or  some  other  medium  of  support  for 
the  patient  when  immersed.  If  the  bath-tub  is  of  metal,  one  rheophore 
of  the  battery  employed  is  attached  to  the  tub,  while  the  other  is 
attached  to  an  electrode  held  by  the  patient  or  placed  in  contact  with 
his  l)od_y.  If  the  tub  is  of  a  non-conducting  material,  both  electrodes 
may  be  placed  in  the  water.  The  electrodes  emploj'ed  should  be  A'ery 
large  (often  running  the  entire  length  of  the  tub),  in  order  to  allow 
of  as  great  a  diffusion  of  the  electricity  as  possible.  The  fluid  in  the 
tub  may  be  simple  water,  or,  preferable,  a  solution  of  salt,  soda,  or 
an  acid. 

The  battery  employed  for  a  bath  should  have  Aery  large  plates,  so 
as  to  generate  an  abundant  quantity  of  electricity  without  a  very  high 
electro-motive  force. 

Personally,  I  am  not  a  strong  advocate  of  this  method  of  treatment. 
It  violates  one  of  the  fundamental  principles  of  electrical  treatment  of 
localized  affections  in  that  it  does  not  confine  the  polar  action  to  the  part 
or  parts  diseased.  In  the  second  place,  I  have  not  found  its  tonic  action 
to  equal  that  of  general  faradization  or  general  galvanization. 

Strong  claims  have  been  made  in  its  favor  as  a  remedy  for  tremor 
(especiall}'  of  the   alcoholic  and  mercurial  varieties)   and   for  chronic 


692  LECTURES   ON  NERVOUS   DISEASES. 

articular  rheumatism,  but  I  am  not  yet  convinced  tliat  they  are  to  be 
regarded  as  well  established. 

If  the  reader  desires  to  try  this  method  of  treatment  in  any  case,  it  is 
well  to  know  that  the  temperature  of  the  bath,  as  well  as  tlie  strength  of 
the  current  employed,  should  be  modified  by  the  condition  of  the  patient. 
The  duration  of  the  bath  should  never  exceed  thirty  minutes,  and  ten 
minutes  will  generally  suffice.  The  current  should  be  strong  enough  to 
be  perceived  by  the  patient  in  all  eases.  The  elements  of  the  cells 
employed  to  generate  the  current  should  be  large,  in  order  to  insure 
quanlit)/  as  well  as  electro-motive  force. 

The  Relief  of  Painful  Points. — One  of  the  most  generally  useful 
effects  of  electricity  is  the  relief  which  it  affords  in  many  cases  to  pain. 
Of  all  the  methods  of  treatment  of  neuralgia  now  employed,  I  consider 
electricit}',  in  some  of  its  various  forms  of  application,  b3'  far  the  most 
efficacious.  Personally,  I  have  almost  discarded  internal  medication  for 
the  relief  of  this  class  of  sufferers. 

In  the  majority  of  subjects  afflicted  with  neuralgia,  painful  points 
may  be  detected  along  the  course  of  the  affected  nerve  or  its  branches. 
Tiiese  are  situated,  as  a  rule,  where  the  nerve  gives  off  a  branch  or 
bifurcates,  and  also  where  it  passes  through  a  foramen.  Sometimes 
it  is  necessary  to  make  pressure  along  the  course  of  the  nerve  to  detect 
the  existence  and  seat  of  these  points. 

Xow,  it  should  be  remembered  that  the  successful  electrical  treatment 
of  neuralgia  de[)ends  largely  in  some  cases  upon  the  direct  treatment  of 
these  painful  j^oints.  They  seem  in  some  way  to  have  a  relationship 
with  both  the  production  and  relief  of  some  types  of  neuralgia,  as  well  as 
spasm  of  the  muscles,  ataxic  symptoms,  and  other  forms  of  nervous 
diseases.  These  points  may  be  the  seat  of  a  localized  periostitis,  a 
circumscribed  inflammatory  exudation,  a  neuritis,  an  enlarged  gland, 
and  many  other  conditions  which  create  nervous  phenomena.  In  a  few 
instances  the  symptoms  even  of  ataxia  have  been  relieved,  by  the  elec- 
trical treatment  of  painful  points  in  the  region  of  the  spinous  and  trans- 
verse processes  of  the  vertebne,  by  men  of  note,  among  whom  mny  be 
mentioned  Brenner.  Remak,  Meyer,  Legros,  and  others. 

The  steps  which  3^011  should  employ  in  the  treatment  of  painful 
points  are  as  follow  :  1.  Use  the  galvanic  current,  employing  from  three 
to  eight  Grenet  cells.  2.  Apply  the  anode  to  the  painful  spot,  and  keep 
it  stationary  at  that  point.  3.  Place  the  cathode  at  some  inditierent 
point,  preferably  the  sternum.  4.  Do  not  use  a  current  which  will  be 
excessively  painful  to  the  patient,  nor  exceed  five  minutes  in  the  appli- 
cation. I  frequently  do  not  allow  the  duration  of  the  current  to  exceed 
two  minutes  at  a  sitting.  It  is  advisable,  in  persistent  cases,  to  make 
the  applications  daily. 


GENERAL   ELECTRO-THERAPEUTICS.  C93 

Of  late  some  experiments  luive  been  made,  with  apparent  benefit,  be- 
having patients  of  this  class  wear  over  the  painful  points  a  piece  of 
metal,  connected  with  another  piece  of  metal  (which  is  also  in  contact 
witii  the  skin)  hy  an  insulated  wire.  The  best  metals  are  zinc  and  cop- 
per. Tiie}^  should  be  brightly  polished  before  the  application,  and 
should  have  a  piece  of  dampened  linen  between  them  and  the  skin. 
The}'  may  be  worn  continuouslj^  for  weeks,  or  changed  each  day  on 
retiring  and  rising. 

Some  authors  recommend  the  employment  of  very  feeble  galvanic 
currents  for  an  hour  or  two  at  each  sitting^  the  anode  being  placed  over 
the  painful  point.  Le  Fort  goes  so  fi\r  as  to  suggest  the  propriet}'  of 
applying  such  currents  continuously  for  weeks,  by  means  of  ordinary 
rheophores  and  electrodes,  when  fatt}'  changes,  contractures,  or  reflex 
paralyses  are  to  be  combated. 

P]lectro LYSIS.— When  a  galvar.ic  current  is  concenti-ated  within 
animal  tissue  by  a  close  approximation  of  the  electrodes,  or  when,  by 
means  of  the  "  polar  method  "  and  insulated  needles,  a  galvanic  current 
of  high  intensity  is  made  to  traverse  some  selected  spot  upon  the  human 
body,  there  is  apt  to  be  a  chemical  decomposition  of  the  water  and  salts, 
and  a  coagulation  of  the  albuminous  elements  of  the  tissue  tluis  acted  upon. 
The  salts  are  then  separated  into  their  bases  and  acids,  while  the  water 
is  simultaneously  decomposed  into  hydrogen  and  oxA'gen.  The  positive 
pole  attracts  to  it  the  acids  and  the  oxygen ;  the  negative  pole  attracts 
to  it  tlie  alkalies  and  the  hydrogen.  For  this  reason  the  insulated  needles 
tend  to  become  oxidized  when  thej^  are  connected  with  the  positive 
rheophore.  They  do  not  become  so  when  attached  to  the  negative  rheo- 
phore.  The  free  alkalies  deposited  at  the  negative  electrode  are  apt,  on 
the  other  hand,  to  cause  destructive  effects  upon  adjacent  tissues.  These 
are  greatly  in  excess  of  that  produced  by  the  oxidation  of  the  metal 
points  of  the  insulated  needles  Avhen  joined  to  the  positive  rheophore. 

When  we  wish  to  test  the  strength  of  the  current  which  we  propose 
to  employ  for  electrolysis,  it  may  be  easily  done  by  sending  the  current 
through  the  white  of  an  egg  for  tvventy  or  thirty  minutes.  In  that  time 
it  should  coagulate  the  albumen. 

In  order  to  reach  the  parts  upon  which  we  most  desire  to  perform 
electrolysis,  it  is  often  necessary  to  perforate  the  skin  and  the  muscles. 
To  do  this,  needles  are  employed.  They  should  be  insulated  with  hard 
rubber,  collodion,  or  shellac,  except  at  their  point  for  one-half  inch,  and 
the  uncovered  part  should  be  gilded,  as  a  rule,  in  order  to  prevent  its 
oxidation.  They  should  be  from  two  to  five  inches  long  ;  should  be 
strong  enough  to  penetrate  tissues  without  a  liability  of  breaking  ;  should 
be  as  small  as  is  consistent  with  the  current-strength  to  be  employed; 
and  should  be  so  arranged  as  to  enable  the  operator  to  adjust  them  in  a 


694 


LECTURES    ON   NERVOUS   DISEASES. 


handle  to  whicli  one  of  the  rheophores  of  the  battery  may  he  attached. 
Ordinary  sewing-needles  strung  on  a  wire  may  be  employed  in  treating 
superficial  naevi,  tumors,  etc.,  if  j-ou  lack  the  instruments  specially 
designed  for  the  purpose.  You  may  shellac  them  for  insulation  if 
deemed  best. 

It  is  very  important,  in  some  cases,  that  the  insulation  of  the  needles 
emplo^'ed  be  as  perfect  as  possible;  and  that  the  tips  of  the  needles  be 
triangular  or  lancet-shaped,  in  order  that  they  may  penetrate  the  skin 
with  ease.  The  needles  and  handle  required  can  be  bought  of  any 
manufacturer  of  electrical  appliances. 

The  batterj-  employed  for  electrol3'sis  need  not  be  unlike  that  for 
ordinary-  medical  purposes.  Twenty-four  of  Grenet's  cells  will  produce 
a  sufficient  intensity  of  current,  provided  the}'  are  fi'eshl}'  filled.  Robin's 
statement  that  a  current  of  fort3^-five  milliamperes  is  requisite  must  be 
based  upon  a  very  limited  external  resistance.  It  is  well  to  use  a  battery 
of  greater  power  than  is  actually  required,  so  that  fresh  cells  can  be 
added  without  breaking  the  current  during  the  operation,  when  deemed 


Fig.  1S6. — Electrode  for  Electrolysis 
(with  three  insulated  needles). 


Fig.  1S7. — Electrode  for  Electrolysis. — 
The  needles  are  fine  and  numerous,  and  are 
arranged  as  shown  at  a.  This  is  an  excel- 
lent device  for  atTecting  the  cureof  diffused 
nsevi,  small  glandular  tumors,  etc. 


necessar}'.  Personally,  I  use  insulated  copper  wire  for  rheophores  when 
performing  electrol3'sis,  in  preference  to  the  tinsel  cords  commonh'  em- 
ploj'ed  for  electric  applications.  The}'  are  less  flexible  than  the  tinsel 
cords,  but  they  are  vastly  superior  to  them  as  conductors. 

Electrolysis  has  been  emploj^ed  for  the  following  purposes,  with 
more  or  less  success  : — 

1.  The  coagulation  of  blood  in  aneurismal  sacs. 

2.  The  relief  of  nsevi  and  erectile  tumors. 

3.  The  cure  of  cystic  tumors. 

4.  The  cure  of  goitre. 

5.  The  cure  of  ecchinococci. 

C.  The  cure  of  ovarian  cysts,  and  those  of  the  broad  ligament. 
"I.  The  cure  of  urethral  stricture. 

8,  The  cure  of  malignant  and  fibroid  growths. 

9.  The  cure  of  hydrocele. 

10.  The  destruction  of  the  foetus  in  extra-uterine  pregnancy. 

11.  The  removal  of  cicatrices,  polypi,  and  other  new  formations. 

12.  .The  destruction  of  superfluous  hairs  and  their  follicles. 


GENERAL   ELECTEO-THERAPEUTICS.  695 

Since  mam-  of  these  conditions  come  under  tlie  observation  of  the 
neurologist,  either  as  a  factor  in  the  causation  of  nervous  symptoms  or 
as  co-existing  troubles  which  demand  relief,  it  may  not  be  inappropriate 
to  hastily  dwell  upon  the  electrical  treatment  of  such  conditions  in  a 
volume  of  this  character. 

Respecting  the  ti^eatment  of  large  aneurianial  sacs  by  this  method, 
statistics  show  that  the  operation  merits  more  general  recognition,  as  a 
means  of  possible  cure  of  intra-thoracic  and  abdominal  aneurisms  wliich 
cannot  be  safely  treated  by  ligation,  than  it  has  received.  Nine  cures 
out  of  thirty-seven  cases  have  been  collected  by  Duncan  from  various 
sources;  and  Bartholow  has  since  collected  others  which  have  been 
benefited  b^'  it,  although  not  positively  cured.  In  none  of  these  cases, 
so  far  as  I  can  ascertain,  was  the  current-strength  measured  by  a  gal- 
vanometer. There  is  reason  to  hope  that  the  operation  may  become 
more  generally  employed  when  the  steps  of  the  procedure  necessary  to 
its  success  are  determined  with  greater  exactness.  There  seems  to  be  a 
doubt,  as  yet,  regarding  the  best  method  both  of  generating  and  direct- 
ing the  current,  so  as  to  prevent  suppuration  and  secondary  hemorrhage. 
In  two  cases  of  blood-sacs  upon  the  ftice,  intrusted  to  my  care,  I  have 
succeeded  in  consolidating  the  tumor  and  effecting  its  radical  cure  by 
this  means  without  suppuration  or  other  complications.  I  employed  the 
positive  rheophore  for  tlie  needles  and  placed  the  cathode  at  the  nape 
of  the  neck  in  both  cases.  The  duration  of  the  two  sittings  in  each  case 
was  about  ten  minutes,  and  twenty-four  Grenet  cells  were  employed.  I 
believe  that  the  anode  produces  the  firmest  clot ;  hence  the  danger  of  hem- 
orrhage on  the  withdrawal  of  the  needles  is  less  than  when  the  cathode 
is  employed.  The  risk  of  embolism,  as  a  result  of  disintegration  of  the 
clot,  does  not  seem  to  be  so  gi-eat  as  one  might  at  first  imagine. 

The  employment  of  electrolysis  in  cystic  tumors  of  the  neck,  the 
ovaries,  and  the  thyroid  gland,  has  been  resorted  to  by  many  experi- 
menters of  note.  Among  these  may  be  mentioned  Althaus,  Amussat, 
Ultzmann,  Clemens,  Semeleder,  and  others.  Some  of  the  cases  reported 
seem  to  point  toward  this  method  of  treatment  of  these  diseased  con- 
ditions as  potent  and  comparatively  devoid  of  danger  if  properly  carried 
out. 

The  treatment  of  vrethral  stricture  by  electrolysis  I  have  alwa^'S 
heretofore  combated,  chiefly  because  I  think  it  less  safe  and  far  less 
certain  than  gradual  dilatation.  I  must  confess,  however,  my  prejudices 
may  be  more  or  less  without  foundation.  My  perusal  of  the  reported 
cures  by  tliis  method  has  not,  as  yet,  carried  to  my  mind  a  thorough 
conviction  of  the  permanency  of  the  cure.  The  method  still  seems  to 
me  to  lack  absolute  precision,  which  should,  to  my  mind,  form  the  basis 
of  all  surgical  procedures  within  that  canal.     I  am  having  made  some 


696  LECTURES   ON   NERVOUS   DISEASES. 

modifications  of  urethral  electrodes  which  I  believe  will  insure  greater 
precision  than  any  yet  devised. 

Ordinary  cases  of  goitre,  and  the  enlargement  of  the  thyroid  gland 
ivhich  accompanies  Basedow's  disease^  have  been  cured  by  electrolysis. 
Rockwell  and  Butler  have  reported  some  astonishing  results  in  the 
treatment  of  exophthalmic  goitre  by  galvanism  of  the  thyroid  gland. 
Rockwell  places  the  cathode  over  that  bod^^  and  the  anode  over  the 
solar  plexus,  combined  with  the  employment  of  the  anode  in  the  auriculo- 
maxiilary  fossa  and  the  cathode  over  the  eilio-spinal  centre  (cervical 
segments  of  the  spinal  cord)  at  each  sitting.  His  cases  of  reported  cure 
required  from  fifty  to  sixty-nine  sittings.  Needles  were  occasionally 
employed  upon  the  goitre.  This  treatment  was  supplemented  by  the 
use  of  iron,  zinc,  digitalis,  and  ergot;  and  a  restricted  diet,  with  in- 
structions regarding  the  necessity  of  the  repression  of  the  emotions  and 
passions,  was  enforced. 

The  arrest  of  extra^-uterine  pregnancy  b}' electrolysis,  and  also  "by 
shocks  transmitted  through  the  sac  from  Leyden  jars  charged  with  static 
electricit}^  from  a  galvanic  battery,  and  also  from  a  faradaic  machine, 
constitutes,  perhaps,  one  of  the  most  successful  and  remarkable  contri- 
butions to  medicine. 

The  treatment  of  cancer  by  electrolysis  has  been  followed  by  satis- 
factory results  in  some  cases,  according  to  the  observations  of  Beard, 
Butler,  Mussey,  and  Neftel.  The  question  of  accurate  diagnosis  of  the 
cases  reported  as  cured  must  still  be  considered  as  unsettled.  The 
results  apparently  obtained  should  certainly  awaken  the  profession  to  a 
trial  of  this  metiiod  of  treatment  of  a  malady  which  internal  medication, 
caustics,  and  the  knife  seem  powerless  to  combat. 

Bartholow  reports  a  cure  of  four  out  of  six  cases  of  fibroid  tumors  of 
the  breast  by  electrolysis.  The  remaining  two  patients  failed  to  continue 
treatment  for  a  sufficient  length  of  time.  He  did  not  emplo}'  needles  in 
an\'  of  these  cases. 

The  relief  of  hydrocele  by  the  introduction  of  two  needles  connected 
with  the  rheophores  of  a  galvanic  battery  and  brought  within  a  half-inch 
of  each  other  at  their  points  has  been  reported  by  Rodolfi,  Frank,  Bar- 
tholow, and  others.  Some  of  the  cases  reported  as  cured  required  only 
one  application. 

In  dismissing  this  subject  it  ma}^  be  well  to  summarize  the  effects 
of  electrolysis,  as  follows  : — 

1.  A  feeble  current  tends  to  cause  dilatation  of  the  capillaries  and 
the  lymphatic  vessels,  and  thus  to  aid  in  absorption. 

2.  A  stronger  current  decomposes  the  salts  and  the  water  of  tissues, 
and  coagulates  the  albuminoid  elements. 

3.  A  disintegration  of  the  tissues  immediately  adjacent  to  the  pole 


GENERAL   ELECTRO-THERAPEUTICS.  697 

which  produces  the  effects  previously  described  takes  place,  with  an 
escape  of  bubbles  of  gas,  when  the  decomposition  of  tissues  is  active. 

4.  As  an  eschar  may  be  formed  bj'  a  current  of  great  intensity,  it 
is  maintained  by  some  authors  that  tlie  cicati'ix  which  results  from  such 
a  slough  is  soft  and  pliable  if  the  eschar  has  been  made  by  the  anode, 
and  dense,  with  a  tendency  to  contract,  when  due  to  cathodal  action.  I 
am  unable  to  confirm  or  deny  this  statement. 

5.  Tiie  danger  in  electrolysis  is  that  of  "doing  too  much"  rather 
than  too  little.  Tlie  former  error  cannot  be  repaired ;  the  latter  can  by 
re})eated  sittings. 

6.  When  an  escharotic  effect  is  desired,  it  is  well  to  have  the  needles 
made  of  zinc.  The  decomposition  of  the  chloride  salts  forms  indirectl}^ 
the  chloride  of  zinc,  because  the  liberated  chlorine  attacks  the  needle. 
This  is  absorbed  by  the  tissues  adjacent  to  the  needle,  and  an  escharotic 
effect  is  thus  produced.  In  the  treatment  of  malignant  growths  such 
needles,  with  currents  of  wealc  intensity',  and  long  sittings,  seem  particu- 
larly well  adapted.  This  method  is  almost  painless,  and  has  produced 
excellent  results  in  some  cases  reported. 

7.  The  introduction  of  needles  into  the  tissues  is  not  an  absolute 
necessity  when  treatment  by  electrol3'sis  is  indicated.  The  same  effects 
to  a  lesser  degree  may  be  obtained  by  placing  the  electrodes  in  contact 
with  cutaneous  or  mucous  surfaces. 

8.  The  employment  of  iron  needles  has  been  suggested  for  the  rapid 
coagulation  of  blood,  on  account  of  the  styptic  effect  of  the  chloride  of 
iron  which  tends  to  form  by  the  liberation  of  chlorine  from  the  chlorides 
of  sodium,  potassium,  and  calcium. 

The  Galvano-Cautery. — When  a  large  quantity  of  electricitj^  is 
forced  through  the  resistance  offered  to  its  passage  by  a  platinum  wire 
or  a  strip  of  platinum  (usually  bent  into  the  form  of  a  knife),  the  heat 
produced  causes  the  platinum  to  rapidly  approach  redness  or  whiteness. 
Such  an  arrangement  is  known  as  a  "  cautery  loop "  or  a  "  cauter}- 
knife."  The  battery  which  is  employed  to  generate  electricity  in  sufficient 
quantity  to  accomplish  such  a  result  is  known  as  a  "cautery  battery." 
In  cautery  batteries  the  plates  are  large  and  near  together;  hence  unusual 
precautions  have  to  be  taken  to  prevent  "polarization,"  which  takes 
place  veiy  rapidly  on  account  of  decomposition  of  the  fluid  in  which  the 
elements  are  immersed. 

Of  all  the  devices  which  have  been  suggested  to  overcome  this 
ditllculty,  I  prefer  that  of  Dr.  Piffard.  In  the  battery  devised  by  him 
tiie  zinc  plates  are  perforated,  so  that  the  fluid  can  be  forced  through 
tliem  upon  tlie  platinum  plates  b}'  means  of  a  rocking  motion  when  the 
battery  is  in  action.  The  assistant  who  operates  the  batter}'  can  produce 
any  degree  of  heat  required  b}'  making  tiie  plates  move  slowly  or  rapidly 


698 


LECTURES   ON  NERVOUS   DISEASES. 


through  the  fluid.  The  key-board  of  the  battery  is  so  connected  by 
means  of  large  thumb-screws  that  the  elements  can  be  connected  for 
either  quantity  or  intensity,  as  the  operator  may  desire.  The  rheophores 
are  composed  of  large  copper  wire,  heavily  insulated  with  rubber. 

I  have  made  several  improvements  upon  the  original  Pirtkrd  battery 
of  late,  which,  in  m}'  opinion,  will  increase  the  ease  of  working  the 
instrument.     The}'  are  not,  as  yet,  fully  perfected. 

It  ma}'  be  advisable  to  again  impress  upon  3'ou  the  fact  that  batteries 
designed  for  ordinary  medical  purposes  are  totally  unfit  for  heating  a 
cautery  loop  or  producing  an  electric  light.  A  battery  designed  for 
cauterv  purposes  is  also  totally  unfit  for  other  purposes  in  medicine. 


(*) 

Fig.  ISS — Pipfakd's  Cauteky  Battery. — (a)  The  battery  as  suspended  when  not  in  action. 
(^)  Arrangement  of  the  top  of  this  battery,  showin>j  the  screws  which  regulate  the  connec- 
tions between  the  different  cells  The  battery  is  rocked  during  its  action  to  prevent  extreme 
polarization.  By  making  the  movement  slow  or  rapid,  the  heat  of  the  loop  or  knife  may 
be  regulated  at  will. 

In  operations  upon  the  tongue,  nose,  pharynx,  uterus,  vagina,  rectum, 
and  in  some  other  regions,  the  galvano-cauter}'  seems  destined  to  super- 
sede the  scalpel  and  ecraseur.  No  blood  need  be  lost  in  amputations  of 
considerable  magnitude,  provided  the  operation  is  skilfulh^  performed. 
If  the  loop  is  employed,  it  is  slipped  when  cold  over  the  part  to  be 
removed.  It  can  be  adjusted,  therefore,  with  every  precaution  against 
accident.  After  the  current  is  turned  on,  the  heat  of  the  wire  even  can  be 
regulated  witii  great  precision.  Care  should  be  exercised  against  draw- 
ing the  wire  too  closely  to  the  handle,  and  in  selecting  a  wire  which  will 
not  burn  off  or  prove  too  large  for  the  battery  employed.  As  in  all  sur- 
gical procedures,  this  instrument  should  be  handled  by  an  expert.  It 
is  W'cll  for  a  novice  to  jjractice  upon  pieces  of  meat  or  bone  until  he 


GENERAL  RULES  GOVERNING  ELECTRO-THERAPEUTICS.   699 

familiarizes  himself  with  the  details  of  its  use,  in  case  he  meditates  per- 
forming an  operation  upon  a  human  subject.  When  operations  are  to  be 
performed  within  the  mucous  cavities  of  the  body,  the  patient  has 
frequently'  to  be  trained  to  tolerate  the  necessary  manipulation.  A 
dnll-red  heat  is  preferable  to  a  white  heat  in  dividing  vascular  tissues, 
and  it  is  very  important  that  the  division  be  slowly  performed.  When 
the  skin  is  to  be  embraced  within  the  loop,  it  is  well  to  divide  it  first 
with  a  cautery  knife,  and  subsequently  to  adjust  the  wire. 

The  cautery  knife  has  been  successfully  used  in  removing  cancerous 
growths  within  mucous  cavities,  in  tubal  pregnane}',  in  tracheotomy, 
in  extirpation  of  the  breast,  and  mau}^  other  similar  procedures. 

An  attachment  to  the  cautery  battery,  known  as  the  "  dome  cautery," 
consists  of  a  coil  of  platinum  wire  over  a  cone  of  porcelain.  These  may 
be  of  any  size,  and  the  porcelain  cone  may  be  omitted  if  deemed  neces- 
sary. It  may  be  emi)loyed  in  destroying  hypertrophied  tonsils,  luemor- 
rlioids,  polypi,  nffivi,  epithelioma,  etc. 

The  great  advantage  which  the  galvano-cautery  has  over  the  use  of 
the  knife  is  tlie  absence  of  hemorrhage  and  of  great  pain.  The  platinum 
knife  can  be  made  of  any  form  desired.  There  is  no  limit  to  special 
forms  of  attachments  which  may  be  devised  to  simplify  its  use  in  dillerent 
regions  of  the  body. 

In  operating  upon  the  tongue,  needles  may  be  passed  through  the 
organ  in  front  of  the  site  selected  for  the  loop,  so  as  to  prevent  slipping 
of  the  wire.  Bryant,  who  has  had  an  extensive  experience  in  this  oper- 
ation, recommends  a  twisted  wire  rather  than  a  large  one.  There  is  some 
reason  to  believe  that  the  heat  tends,  moreover,  to  destroy  (in  the  case 
of  cancerous  growths)  the  germs  of  the  disease  which  might  elude  the 
knife. 

GENERAL  RULES  GOVERNING  ELECTRO-THERAPEUTICS. 

Before  we  pass  to  the  consideration  of  special  methods  of  employing 
electricity  in  the  treatmeat  of  disease,  it  seems  to  me  advisable  to  sug- 
gest a  few  rules  which  may  possibly  aid  you  in  deciding  where  and  how 
to  direct  your  treatment  in  any  special  case.  There  are,  of  course,  some 
exceptions  to  each  of  these  rules;  but  they  are,  nevertheless,  sufficiently 
accurate  to  be  used  as  guides  in  your  practice : — 

1.  Soak  your  electrodes  in  a  weak  solution  of  table-salt,  not  in 
simple  w\ater.  This  diminishes  the  resistance  afforded  by  the  skin  at 
least  fifty  per  cent. 

2.  Always  press  your  electrode  firmlj'  and  evenlj'  against  the  i)art 
which  it  touches.  This  renders  the  current  employed  an  even  one  to  the 
patient  and  assists  in  its  conduction. 

3.  Put  a  milliampere-meter  or  a  galvanometer,  as  well  as  the  body 
of  your  patient,  into  circuit,  and  record  all  your  observations,  respecting 


700         s  LECTURES   ON   NERVOUS   DISEASES. 

the  current-strength  enii)loyed,  from  its  scale.  It  is  neither  scientific 
nor  accurate  to  simply  record  the  number  of  cells  em[)loyed.  Cells  grow 
weak  by  long-continued  use,  by  polarization,  and  other  causes.  In  ease 
a  faradaic  instrument  is  employed,  a  galvanometer  is  useless  ;  hence  j'ou 
sliould  record  the  number  either  of  centimetres  or  inches  of  the  primary- 
or  secondary  coil  employed. 

4.  Always  endeavor  to  applj'  one  of  the  poles  to  the  part  wliich  is 
diseased.  The  plates  of  Ziemssen  which  I  incorporate  in  this  volume 
indicate  the  situation  of  the  "motor  points"  of  the  head,  trunk,  and 
extremities.  Such  plates  will  enable  you  to  direct  your  treatment  to 
an}'  special  nerve  or  muscle. 

5.  Acquire,  by  frequent  experimentation  upon  yourself,  a  knowledge 
of  the  effects  of  different  current-strengths,  the  situation  of  most  of  the 
more  important  nerve-trnnks.  the  formula?  of  contraction  of  healthy  nerve 
and  muscle,  and  all  other  information  necessary  to  the  use  of  electricity 
in  medicine. 

6.  Never  use  too  strong  a  current  upon  a  patient  at  the  first  sitting. 
It  may  frighten  him,  and  he  may  never  return.  It  is  always  best  to 
begin  with  weak  currents;  in  the  majority  of  cases  weak  currents  are 
indicated  rather  than  strong  ones. 

T.  If  you  have  no  galvanometer,  the  intensit}'  of  a  galvanic  current 
can  be  approximately  determined  by  the  burning  sensation  produced  in 
the  skin  b}'  the  electrodes  Avhen  tlie}'  are  applied  to  it. 

8.  The  "  polar  method  "  is  more  painful  when  the  faradaic  current 
is  emploA'ed  than  when  the  galvanic  current  is  used.  It  is  not  well  to 
separate  the  poles  of  a  faradaic  machine  too  widely  ;  pain  is  intensified, 
and  no  special  benefit  is  gained  b}^  so  doing.  Remember  that  the  fara- 
daic current  has  no  fixed  polarity.  A  galvanometer  will  record  the 
difference  between  the  current  produced  b}-  the  "  make  "  and  "  break  " 
of  the  circuit  onl}' ;  hence  it  is  of  no  value  in  determining  the  intensit}' 
of  the  faradaic  current  actuallj-  administered  to  a  patient. 

9.  The  "  polar  method  "  is  absolutely  requisite  to  electro-diagnosis 
when  the  galvanic  reactions  of  nerve  or  muscle  are  being  tested.  It  con- 
stitutes the  best  method  also  of  administering  the  galvanic  current  for 
therapeutical  purposes,  because  it  is  usually  im[)ortant  that  tlie  anode  or 
cathode  exert  its  special  influence  upon  the  part  diseased.  The  farther 
apart  you  place  the  poles,  the  less  is  the  effect  of  the  indifferent  or  neutral 
pole  upon  the  part  wliich  you  wish  chiefly  to  influence. 

Although  clinical  experience  seems  to  prove  that  we  obtain  different 
results  in  the  majority  of  cases  by  employing  the  anode  or  catiiode  upon 
the  part  to  be  influenced,  I  am  inclined  to  question  the  correctness  of  the 
view  that  those  effects  are  in  any  way  dependent  upon  the  direction  of 
the  transmitted  current.     AVe  know  that  it  is  not  possible  to  confine  an 


X 


GENERAL  RULES   GOVERNING  ELECTRO-THERAPEUTICS.       701 

t'lectric  current  to  any  one  channel  by  means  of  animal  tissues.  Every 
current  becomes  diffused  to  a  greater  or  less  extent,  as  is  illustrated  in 
diagrams  prepared  by  Erb  and  other  authors  upon  electro-therapeutics. 
It  is  probably  more  correct  to  view  tlie  special  effects  obtained  by 
employing  the  positive  and  negative  poles  of  a  galvanic  battery  as  the 
etfects  of  the  poles  themselves,  rather  than  the  result  of  the  direction  of 
the  current. 

10.  Remember  that  the  anode  or  positive  pole  of  a  galvanic  battery 
is  the  sedative  pole,  and  the  cathode  or  negative  pole  is  the  stimulating 
or  irritating  pole.  When  the  cathode  is  made  the  indifferent  pole,  it  is 
well  to  use  a  very  large  electrode. 

11.  Do  not  change  the  polarity  of  a  current  during  its  application  to 
a  patient  any  oftener  than  circumstances  demand.  As  a  rule,  it  is 
ininecessary  to  do  so  at  all.  It  causes  unnecessary  irritation,  which 
should  always  be  avoided.  In  the  treatment  of  neuralgia,  diseased  con- 
ditions of  the  brain  or  spinal  cord,  and  painful  points,  it  should  never  be 
done  without  some  special  reason.  It  is  positively  contra-indicated  when 
catalytic  effects  are  desired. 

12.  When  galvanic  currents  to  the  head  are  indicated  (especially  if 
the  current  is  to  be  sent  through  the  brain),  employ  only  those  of  mod- 
erate intensity  (save  in  exceptional  cases),  and  do  not  reverse  the  current 
unless  there  is  good  reason  for  so  doing.  When  you  read  about  thirty- 
cell  currents  being  sent  through  the  brain,  it  is  safe  to  suppose  that  the 
battery  was  not  of  the  most  active  kind,  or  that  the  ability  of  the  patient 
to  endure  such  a  current  was  very  exceptional.  It  is  rare  to  meet  with 
:i,  patient  who  can  tolerate  a  current  of  more  than  from  three  to  six 
milliamperes  through  the  brain,  and  it  is  not  safe  to  break  currents  of 
high  intensity  when  employed  about  the  head. 

13.  Static  electricity  will  sometimes  produce  muscular  contractions 
when  faradaic  currents  will  not.  In  hysterical  conditions,  some  of  the 
spasmodic  diseases,  sciatica,  and  organic  spinal  affections,  it  is  well  to  try 
this  form  of  electricity  when  galvanism  fails  to  afford  relief. 

14.  Respecting  the  duration  of  individual  applications  of  electricity 
in  its  various  forms,  my  experience  teaches  me  that  short  sittings  accom- 
])lish  as  much,  and  often  more,  than  long  ones.  I  seldom  exceed  five  or 
six  minutes,  unless  I  am  endeavoring  to  induce  catalytic  action,  to  benefit 
chronic  articular  rheumatism,  etc. ;  or  Avhen  I  am  employing  general 
faradization,  general  galvanization,  central  galvanization,  electrolysis,  the 
galvauo-cautery,  or  other  procedures  which  require  a  longer  sitting. 
Frequently,  thirty  seconds  to  two  minutes  is  all  that  is  required  when 
some  particular  part  of  the  body  is  alone  to  be  galvanized  or  taradized. 

15.  It  is  impossible  to  lay  down  any  rule  Avhich  will  guide  you  in 
determining  the  frequency  of  the  ai)plications  required  b}-  any  individual 


702  LECTUEES   OX  NERVOUS   DISEASES. 

case.  It  is  seldom  necessary  to  employ  this  agent  oftener  than  every 
day,  and  three  sittings  a  week  will  suffice  in  the  majorit}'  of  cases.  If 
the  disease  is  of  a  chronic  type,  it  is  often  advisable  to  occasionally  dis- 
continue treatment  for  a  few  weeks,  and  then  to  renew  it  with  vigor. 
Experience  has  taught  me  that  the  etieets  of  electricity  are  more  vigor- 
ous after  such  intermissions.  It  is  often  well  to  change  from  galvanic 
to  foradaic,  and  again  to  static  currents,  from  time  to  time,  in  the  treat- 
ment of  obstinate  diseases  which  fail  to  progress  satisfactorily. 

16.  I  would  advise  you  to  be  persistent  in  employing  this  agent 
when  your  judgment  tells  you  that  it  is  advisable  to  begin  it.  Many 
of  the  chronic  forms  of  cerebral  and  spinal  diseases  are  materially  bene- 
fited and  often  completely  cured  by  a  proper  course  of  electrical  treat- 
ment which  has  been  followed,  with  occasional  intermissions,  for  some 
months  during  each  year  for  several  years. 

IT.  As  adjuncts  to  a  course  of  electrical  treatment,  you  will  find 
massage,  baths  of  various  kinds,  a  change  of  climate,  enforced  rest  in 
bed,  and  judicious  internal  medication,  indicated  in  special  cases.  Deli- 
cate subjects,  who  suffer  from  neurastiienia,  hysteria,  persistent 
neuralgias,  mental  depression,  sleeplessness,  morbid  fears,  excessive 
"  nervousness,"  rapid  or  extreme  emaciation,  profuse  and  persistent 
sweating  of  the  palms  or  feet,  d^'speptic  symptoms,  and  the  thousand 
other  manifestations  of  debility,  are  especially  benefited  by  these  adjuncts 
to  a  judicious  use  of  electricity. 

18.  When  simple  excitation  of  motor  or  sensory  nerves  is  demanded, 
the  faradaic  or  static  current  is  the  best  one  to  employ. 

19.  As  a  counter-irritant,  and  in  the  treatment  of  anaesthesia,  dry 
faradization  with  a  wire  brush  excels  all  other  electrical  applications, 
unless  it  be  the  use  of  static  electricity. 

20.  In  spasmodic  diseases,  in  neuralgia,  and  other  like  conditions, 
galvanism  and  static  electricity  are  alone  of  material  service. 

21.  Interrupted  galvanic  currents  are  of  service  when  muscular 
contractions  of  a  forcible  character  are  desired.  When  degeneration  of 
a  nerve  exists,  these  cannot  be  produced  by  the  faradaic  current. 

22.  The  size  of  the  electrodes  modifies  the  density  of  the  current 
directly.  When  large,  the  current  is  less  dense  because  it  is  more  dif- 
fused. The  cathode  should,  as  a  rule,  be  larger  than  the  anode  when 
electrical  applications  are  being  made. 

STATICAL   ELECTRO-THERAPEUTICS. 

We  have  now  discussed  at  some  length  in  this  section  (1)  the 
physics  of  this  form  of  electricitv  ;  (2)  the  improvements  made  from 
time  to  time  in  macliines  designed  to  generate  it ;  and  (3)  the  various 
methods  of  application  of  this  agent.- 


STATICAL   ELECTKO-THEEAPEUTICS.  703 

We  are  now  prepared  to  consider  more  intelligently  the  various 
diseased  conditions  of  the  human  body  which  static  electricity  has  been 
shown  either  to  ameliorate  or  arrest.  In  this  connection  I  take  the 
liberty  of  first  quoting  from  an  admirable  paper  of  my  friend,  Dr.  W.  J. 
Morton,  published  some  years  ago  upon  this  subject,  certain  paragraphs 
which  relate  to  the  rise  and  fall  of  static  electricity  as  a  therapeutical 
agent.     He  says  : — 

"  In  1730  Mr.  Stephen  Gray,  of  London,  first  insulated  and  electri- 
fied a  human  subject,  and  in  1T34  the  Abbe  Nollet  received  the  first  spark 
drawn  from  a  body  thus  insulated.  From  this  incident  undoubtedly 
sprung  the  modern  idea  of  electro-therapeutical  science,  for  Nollet  pur- 
sued electrical  investigations  to  great  lengths,  and  as  early  as  1746  was 
treating  paralytics  by  insulation,  sparks,  and  shocks.  About  this  time, 
also.  Professor  Kruger,  of  Helmstadt,  and  Kratzenstin,  his  pupil,  cured 
paralysis  by  electricity,  and  Kl3'n  cured  by  means  of  sparks  a  paralyzed 
arm.  These  cases  were  the  first  strivings  of  modern  electro-therapeutics, 
but  they  produced  little  effect  on  medical  practice. 

''  It  was  a  publication  in  1748  by  Jallabert,  professor  at  Geneva,  that 
first  drew  the  earnest  attention  of  the  medical  world  to  the  real  curative 
power  of  electricity.  Jallabert  restored  to  perfect  motion  and  sensation 
in  two  months  a  locksmith's  arm  which  had  been  paralyzed  during  fifteen 
3'ears.  In  the  meanwhile  the  invention  and  perfecting  of  the  electric 
machine  and  Leyden  jar  paved  the  immediate  wa^-^  to  the  practical  use 
of  electricity  as  a  remedial  agent,  and  soon,  following  the  success  of 
Jallabert,  the  whole  medical  world  was  awake  on  the  subject  of  medical 
electricity.  At  Montpelier,  under  the  auspices  of  Sauvages,  president 
of  the  Academy  of  Medicine,  the  people  flocked  in  multitudes  to  have 
their  ailments  relieved,  and  so  great  Avas  the  number  of  successful  treat- 
ments that  the  physicians  were  obliged  to  appeal  to  the  priests  to  protect 
them  from  the  charge  of  witchcraft.  Deshais,  in  1749,  wrote  a  disserta- 
tion upon  the  Montpelier  experiences.  Quelmalz,  Linnaeus,  and  Zetzel 
followed  him,  and  from  this  period  onward,  up  to  the  year  1800,  works* 
on  the  subject  multiplied  in  all  countries. 

"  It  is  interesting  to  recall  that  Franklin,  in  1752,  treated  paralytics 
at  Philadelphia  by  statical  electricity. 

"  It  is  evident,  then,  that  statical  electro-thernpeutics  was  already,  at 
the  end  of  the  last  century,  entering  upon  a  marked  career  of  service  to 
medicine  when  galvanism  and  the  voltaic  pile,  in  1800,  extinguished  it  at 
the  very  height  of  its  progress.  It  is  not  improbable  that  its  abandon- 
ment was  a  loss  to  medical  science. 

♦Besides  those  mentioned,  tlie  most  important  are  by  De  Haen,  Watson,  Franklin, 
Priestley,  Gaidane,  Sigaud  de  la  Fond,  Bertholon,  Cavallo,  Wilkinson,  and  Manduyt ;  the 
latter  is  particularly  valuable  to  the  student  of  medico-statical  electricity. 


704  LECTURES  ON  NERVOUS  DISEASES. 

"  Up  to  comptinitively  recent  times  frictioiial  electricity  for  medical 
purposes  was  produced  from  a  single  glass  wheel.  Its  tension  was  low 
and  its  quantity  small.  But  the  invention  of  Holtz,  in  18G5,  marked  out 
for  modern  statical  electricity  the  possibilities  of  a  new  career.  In  the 
Holtz  machine  we  have  an  apparatus  simple  and  durable  in  construction 
and  capable  of  furnishing  electricity  of  high  tension  and  in  great  quan- 
tity. And  by  means  of  the  Leyden-jar  condensers,  and  of  the  possibility 
of  increasing  the  number  of  wheels,  both  tension  and  quantity  are  within 
the  control  of  the  operator.  At  a  given  length  of  spark  or  tension, 
every  additional  wheel  adds  only  to  the  quantity,  and  Holtz  machines 
with  as  many  as  twenty  revolving  wheels  have  been  constructed,  in 
which  the  quantity,  of  course,  was  veiy  great.  This  ver^-  fact  of  a 
greatly  increased  working  quantity  of  statical  electricity  justifies  the 
expectation  that  modern  electro-statical  therapeutics  will  take  a  step 
greatly  in  advance  of  its  past. 

"  Statical  electricity,  as  we  have  already  seen,  has  never  had  fair  play 
in  modern  medicine.  The  older  practitioners  (1740  to  1800)  have  left  us 
glowing  records  of  its  value — records  embodied  in  a  period  of  literature 
still  full  of  fruitful  suggestion  in  other  branches  of  medicine,  though  in 
none  more  advanced  than  in  the  treatment  by  electricity.  The  ph^'sicist 
of  to-day  cannot  neglect  the  work  of  Franklin,  of  Symmer,  of  Du  Faye, 
of  Cavendish,  and  the  long  line  of  the  men  of  their  time  who  unrolled  to 
view  the  mysteries  of  a  new  science.  No  more  can  the  physician  neglect, 
from  a  medical  point  of  view,  De  Haen,  Boze,  Bertholon,  Nollet,  Wilkin- 
son, Cavallo,  Manduyt,  and  a  dozen  others.  True,  the  mantle  of  their 
labors  decked  in  a  degree  the  new  galvanism  and  the  newer  foradaism, 
Avhile  in  the  act  statical  electricity  dropped  from  sight.  It  found  con- 
scientious revivers  in  Sir  William  Gull,  Golding  Bird,  and  Wilks  in  1850, 
and  thereabouts,  and  it  is  gratifying  to  note  in  their  writings  the  highest 
appreciation  of  its  merits.  When  at  last  it  fell  from  their  hands  again 
abandoned,  it  was  only  and  simply  because  of  the  inconvenience  of 
administering  it.  The  machine  of  their  daj-  refused  to  work  in  the  damp 
of  London  fogs,  and  it  was  necessary  in  the  electrical  room  of  Guy's 
Hospital  to  keep  a  large  fire  constantly  burning  to  dry  tlie  air  ;  and  even 
to-day,  in  Paris,  one  may  visit  the  rooms  of  a  practitioner  heated  summer 
and  winter. 

"  But  these  disadvantages  have  now  been  removed.  Statical  elec- 
tricity was  again  revived,  and  with  great  success,  by  Professors  Clemens 
in  Germany  and  Scwanda  in  Austria.  In  France,  its  revival  has  already 
received  a  notable  impetus  emanating  from  the  famous  clinic  at  Salpe- 
triere,  where  the  presiding  care  of  Professor  Chnrcot  and  tlie  efficient 
labors  of  Dr.  Yigouroux  have  each  contributed  to  place  statical  electro- 
tlierapeutics  on  a  scientific  modern  basis." 


STATICAL   ELECTEO-THEEAPEUTICS.  705 

The  remarks  of  Dr.  Morton  which  I  have  quoted  are  peculiaily 
signilicant  in  this  connection.  During  the  years  in  which  I  have  per- 
sonally been  engaged  in  experimenting  with  various  modifications  and 
imi)rovements  upon  the  original  model  of  Holtz's  induction  machine 
which  have  suggested  themselves  from  time  to  time  to  ni}'  mind,  I  have 
had  ample  opportunities  to  observe,  in  the  daily  routine  of  my  practical 
office  work,  the  effects  of  static  electricit}*  upon  many  patients  afflicted 
with  diversified  diseases.  In  preparing  this  article  I  liaA'e  carefully 
searched  through  the  records  of  quite  a  large  number  of  cases  where  it 
has  been  most  successfully  employed  by  me.  I  have  been  struck  in  many 
instances  with  the  rapidity  with  which  it  efi'ected  an  apparent  cure ;  in 
other  cases,  with  the  permanencj'^  of  its  beneficial  results;  and  in  all, 
with  the  simplicity  and  case  of  its  application.  To  a  lady,  for  example, 
it  is  a  matter  of  no  small  moment  that  she  is  freed  from  the  necessity 
of  divesting  herself  of  any  garments  worn,  and  that  almost  anj^  part  of 
the  body  can  be  treated  without  exposure  or  annoyance.  To  the  busy 
practitioner,  also,  to  whom  time  is  valuable,  it  is  not  unimportant  that 
.several  patients  can  be  treated  simultaneously ;  and  that  no  delays  are 
caused  b}'  waiting  for  each  one  to  remove  and  replace  their  clothing. 

Again,  the  application  of  "static  insulation"  is  for  more  agreeable 
than  "  general  foradization  "  or  "  general  galvanization  ;  "  and,  in  my 
experience,  it  is  fully  as  etilcient  in  many  cases  in  its  remedial  action  as 
either  of  the  methods  referred  to.  The  inconvenience  to  the  patient  of 
having  to  disrobe  almost  completely',  and  the  distaste  which  man}- 
naturally  exhibit  to  having  a  wet  electrode  or  the  operator's  wet  hand 
rubbed  over  the  skin  for  from  ten  to  twenty  minutes  is  entirely  obviated. 
With  a  sufficiently  large  insulated  platform  several  patients  can,  if 
desired,  be  given  a  static  bath  in  the  physician's  consulting-room  in  the 
same  period  of  time  as  would  be  consumed  in  administering  general 
faradization  to  one  patient,  and  be  spared  the  annoyances  mentioned. 

I  do  not  mean  to  infer  that  some  cases  do  not  require  the  use  of 
faradaic  or  galvanic  treatment;  nor  would  I  be  construed  as  casting  any 
reflection  upon  the  thex'apeutical  value  of  the  methods  which  were  first 
suggested  and  employed  l\v  Drs.  Beard  and  Rockwell,  of  New  York. 
The  question  at  issue  is  simply  one  of  convenience  to  the  patient  and  the 
phj^sician  ;  provided  that  the  indications  of  the  case  justify  the  trial 
of  the  static  bath  as  a  substitute  for  "  general  faradization  "  or  "■  general 
galvanization." 

In  the  second  place,  I  think  it  has  been  justly  claimed  for  static  elec- 
tricity that  some  of  its  tiierapeutical  effects  are  more  certainly  and  rapidly 
obtained  than  b}'  means  of  any  other  form  of  electrical  application. 

As  examples  of  such  efiects,  I  prominently  mention  (1)  the  re- 
li^f  of  contractured  muscles;    (2)  the  relief  of  certain  forms  of  pain,- 

45 


706  LECTURES   ON   NERVOUS   DISEASES. 

(3)  the  production  of  muscular  contraction  and  the  restoration  of  mus- 
cular power  after  the  '■'■reaction  of  degeneration  "  has  shown  itself;  (4) 
the  improvement  of  muscular  pjower  and  general  sensibility  in  certain 
organic  spinal  diseases ;  and  (5)  the  stimulation  of  the  skin  in  certain 
trophic  neuroses. 

Respecting  this  statement,  I  take  the  liberty  of  again  quoting  certain 
paragraphs  from  the  writings  of  my  friend,  Dr.  Morton.     He  says  : — 

"  We  may  now  ask  the  special  question,  Why,  above  and  beyond  other 
forms  of  electricity,  does  static  electricity  cure  ?  I  will  offer  two  explana- 
tions, and  these  are,  first,  simple  mechanical  disturbances,  followed  by  a 
local  alteration  of  nutrition;  and,  secondl}^,  reflex  action  from  irritation 
of  the  peripheral  distribution  of  nerves. 

"  With  regard  to  the  first,  when  the  electric  discharge  in  the  form 
of  a  spark  takes  place  in  a  resisting  medium  like  the  various  parts  of 
the  human  body  which  are  submitted  to  it,  a  very  great  mechanical 
disturbance  in  the  tissue  at  the  point  of  discharge  must  inevitably  result. 
A  piece  of  paper,  for  instance,  held  between  the  electrode  and  the  skin 
is  perforated  by  the  spark.  A  parallel  to  the  mechanical  action  referred 
to,  though  in  a  less  localized  and  less  powerful  degree,  is  to  be  found  in 
ordinary  physical  exercise  or  in  massage.  From  this  point  of  view, 
static  electricity  by  the  method  of  sparks  has,  in  a  special  degree,  owing 
to  its  high  tension,  great  advantages.  The  spark  sti'ikes  a  sharp,  in- 
cisive, and  penetrating,  though  scarcely  painful  blow,  and,  often  repeated 
in  a  given  region,  creates,  by  simple  disturbance,  a  great  alteration  in  the 
nutrition  of  the  part.  This,  at  least,  is  the  only  way  in  which  I  can  account 
for  the  almost  instantaneous  relief  and  cure,  after  a  few  applications,  of  a 
large  class  of  pains  seated  in  deep  and  superficial  fasciae,  and  due  to  sub- 
acute and  chronic  rheumatism.  Neither  l)listers,  other  violent  counter- 
irritation,  nor  medicine  will  dissipate  these  pains,  while,  on  the  other 
hand,  static  electricity  will  subdue  them  at  once. 

"  The  contraction  of  muscles  is  also  often  due  to  the  same  me- 
chanical eff'ect  of  the  spark,  just  as  muscles  of  the  thigh  may  be  made 
to  contract  by  a  snap  of  tlie  finger  or  sharp  blow  from  a  percussion- 
hammer. 

"  With  regard  to  the  second  explanation, — that  by  reflex  action 
following  a  peripheral  irritation  of  the  terminal  sensory  filaments  and 
endings, — a  very  intricate  question  is  opened,  which  we  can  no  more 
than  glance  at  here. 

"  How  can  simple  electrification  l)y  insulation  and  the  drawing  of 
sparks,  it  is  asked,  produce  the  decided  efiects  that  are  claimed  for  it? 
Static  electricit}',  it  is  said,  owing  to  its  high  tension  accumulates 
merely  on  the  surface  of  the  body,  and  does  not  penetrate  into  the 
deeper  organs,  while  the  spark  is  merely  the  briefest  kind  of  current. 


STATICAL   ELECTRO-THERAPEUTICS.  707 

"  Recent  investigations  on  the  irritutive  action  of  applications  to  the 
skin  have  thrown  a  new  ligiit  upon  this  question,  and  show  that,  though 
previously  unexplained,  the  ettects  of  the  great  accumulation  of  elec- 
tricit}'  on  the  surface  and  the  sharp  blow  of  the  spark  were,  in  truth, 
eftects  based  upon  a  true  physiological  principle, — the  principle  named  by 
Brown-Sequard,  its  recent  expounder,  "the  phenomena  of  inhibition." 
A  few  drops  of  chloroform  applied  to  the  neck  of  a  guinea-pig  produced, 
on  some  occasions,  an  epileptic  attack  ;  on  others,  the  nerves  and  muscles 
became  highly  excitable  to  stimulation. 

"  But  the  most  notable  ettect  of  irritating  applications  of  chloroform, 
as  well  as  other  substances,  was  a  general  antesthesia ;  reflex  symptoms 
were  inhibited  and  muscular  excitability  lost. 

"  An  interesting  element  has  entered  into  our  physiological  and  ther- 
apeutical studies, — that  of  the  reflex  phenomena  of  peripheral  irritation. 
And  we  ma^^  at  once  place  under  this  single  heading  a  large  number  of 
facts  long  familiar. 

"  External  irritant  applications,  in  one  form  or  another,  have  ahva^-s 
formed  an  important  element  in  medical  treatment.  And  most  of  these 
applications  have  been  used  to  relieve  pain,  or  in  some  wa^-  modify-  the 
general  sensibility',  either  in  contiguous  or  remote  parts. 

"  Familiar  examples  are  blisters,  sinapisms,  cupping,  the  actual 
cautery,  ammonia,  the  moxa,aqua  and  acupuncture,  and  in  later  daj^s  the 
magnet,  the  tuning-fork,  and  hypodermic  injections  of  water  into  the 
thoracic  walls  for  the  purpose  of  allaying  the  cough  of  phthisis.  The 
latest  novelty  in  this  direction  is  the  electric  percutor  of  Baudet,  con- 
sisting of  a  tuning-fork  kept  in  vibration  by  electricity,  and  communi- 
cating to  any  desired  nerve  or  part,  by  means  of  a  slender  rod,  the 
mechanical  vibrations  originated  in  the  fork. 

"  Charcot,  after  cautious  experimentation,  has  given  his  adherence 
to  the  statement  that  metals  (metallotherapy)  do  produce  ettects  con- 
tiguous and  remote  when  applied  to  the  skin, — that  the  magnet  also 
produces  similar  efl^ects,  both  upon  general  sensibility  and  muscular 
power.  Yigouroux  has  pointed  out  that  the  vibrations  of  a  tuning-fork, 
either  alone  or  communicated  to  a  sounding-board,  provoke  similar 
phenomena. 

"  Here,  then,  in  this  collection  of  well-known  facts,  and  in  the  broad 
generalization  of  Brown-Sequard,  drawn  from  his  recent  experiments, 
we  have  at  last,  it  seems  to  me,  found  the  law  which  governs  the  results 
produced  and  to  be  expected  from  statical  electrification,  as  well  as  from 
some  other  uses  of  electricity.  This  law  is  the  effect  produced  upon 
remote  parts  by  affecting  the  periplieral  distribution  of  the  sensor}' 
nerves,  and  the  effect  produced  is  most  commonly  relief  of  pain  or  spasm 
in  a  remote  part ;  and  in  this  principle  of  inhibition  from  peripheral 


708  LECTURES   ON  NERVOUS   DISEASES. 

application  may  doubtless  be  found  the  explanation  of  manj'  of  the 
definite  and  hitherto  inexplicable  effects  of  static  electricity. 

"  The  '  insulation '  alone  holds  the  entire  sensory  peripheral  dis- 
tribution of  the  skin  in  its  grasp.  Every  nerve-filament  is  vil)rating,  is 
polarized,  or  atl'ected,  whatever  term  we  choose  to  use,  by  the  tense  la^-er 
of  electricity  or  electrical  influence  collected  on  the  surface,  there  bound 
by  the  natural  laws  of  physics,  and  only  waiting  to  be  drawn  off  by  a 
spark  or  diffuse  itself  graduallj'  into  the  atmosi)here,  while  in  the  spark 
itself  is  found  a  still  more  potent  and  localized  stimulating  agent." 

I  have  quoted  the  preceding  paragraphs  from  the  pen  of  Dr.  Morton, 
because  they  coincide  in  the  main  w  ith  my  own  views ;  the  possible 
exceptions  being  a  few  technical  points  in  which  I  might  not  fully  agree 
with  that  author. 

From  conversations  held  with  him  I  am  led  to  infer  that  his  ex- 
periences and  my  own  have  been  generally  in  accord  respecting  the 
therapeutical  effects  of  each  of  the  several  methods  of  statical  applica- 
tions already  described  by  me  in  preceding  pages. 

It  is  extremely  difficult  to  formulate  general  deductions  respecting 
any  therapeutical  agent.  Such  attempts  necessaril}^  tend  to  evoke 
criticism,  because  exceptions  to  every  general  statement  may  be 
brought  forward  as  evidences  of  their  nnrelial)ility.  I  am,  however, 
inclined  to  offer  the  following  general  deductions  respecting  static  elec- 
trical applications  for  the  benefit  of  the  reader,  with  the  proviso  that 
they  may  not  apply  to  every  case,  and  that  they  be  not  construed  too 
literall}'^ : — 

First. — My  experience  has  not  confirmed  the  view  (heretofore  ad- 
vanced by  some  authors)  that  the  positive  pole  of  a  static  machine  has  a 
"  tonic  "  and  the  negative  pole  a  "  depressant  "  action. 

I  have  found,  after  repeated  experimentation,  that  either  pole  seems 
to  answer  equally  well  upon  most  patients.  I  commonly  employ  in  my 
office  the  positive  pole,  however,  because  it  happens  to  be  the  most  con- 
veniently connected  witli  the  patient. 

Second. — As  a  curative  agent,  /  regard  static  electricity  as  of  great 
value. 

While  galvanism  must  always  hold  a  preeminent  place  in  electrical 
therapeutics,  because  of  the  chemical  effects  so  obtained,  there  are 
certain  diseased  conditions  in  which  static  electricity  is  unquestionably 
superior  to  faradaism  and  galvanism. 

Third. — It  has  been  shown  in  preceding  pages  that  the  static  in- 
duced current  fulfills  all  the  known  indications  of  faradaism. 

It  has,  moreover,  two  great  advantages  over  the  faradaic  instrument, 
namely,  that  a  constant  polarity  is  olitained  and  a  much  greater  electro- 
njotive  force.     It  is  also  less  painful  than  the  faradaic  current. 


STATICAL   ELECTEO-THEEAPEUTICS.  709 

Fourth. — Static  electricity  possesses  a  decided  advantage  in  some 
cases  where  faradization  or  galvanization  have  either  given  negative  re- 
sults or  have  apparently  lost  their  remedial  power  after  their  use  has  been 
too  long  continued. 

It  is  a  common  expedient  witli  medical  electricians  to  shift  from  one 
form  of  current  to  another  from  time  to  time  whenever  the  progress  of  the 
case  seems  unsatisfactory.  Under  such  circumstances  franklinism  forms 
another  link  to  the  chain,  and  greatly  aids  us  when  faradaism  and  gal- 
vanism have  both  proven  inefficient. 

Fifth. — I  have  found  heavy  static  sparks  to  surpass  any  other  form 
of  electrical  application  for  the  relief  of  contractured  muscles. 

The  sparks  are  withdrawn  from  the  part  so  affected  in  rapid  suc- 
cession for  about  five  minutes. 

Post-paralytic  contracture,  old  deformities  from  preternaturally 
shortened  muscles,  and  the  various  forms  of  obstinated  and  protracted 
tonic  muscular  spasm  often  jield  like  magic  to  the  influence  of  heavy 
sparks. 

Sixth. — It  is  well  known  that  certain  forms  of  pain  often  disappear 
at  once  after  static  applications. 

The  most  marked  t\pe  of  pain  so  relieved  is  the  so-called  '  rheu- 
matic muscular  pain, ^''  or  that  observed  in  genuine  muscular  rheumatism. 
I  have  seen  many  such  cases  where  one  application  of  heavy  sparks  to 
the  seat  of  pain  for  a  few  minutes  has  caused  permanent  relief. 

Again,  neuralgias  of  a  distressing  kind  are  often  dissipated  after  a 
few  applications  of  heavy  indirect  static  sparks  for  from  five  to  ten 
minutes  at  a  sitting. 

Finally,  I  know  of  no  other  agent  which  exerts  so  marked  an  effect 
of  a  happy  kind  upon  the  "  lightning  pains "  observed  in  locomotor 
ataxia  as  does  the  heavy  static  spai'ks. 

Seventh. — The  application  of  the  spark,  both  hy  the  direct  and  indi- 
rect methods  (Figs.  176  and  177)  excites  pjoicerful  muscular  contractions. 

This  effect  is  often  desired  in  the  treatment  of  hemiplegia  and  other 
forms  of  motor  paralysis. 

Some  authors  recommend  the  employment  of  "static  shock"  (Fig. 
178)  for  cases  of  paralysis  of  long  standing;  but,  personally,  I  am  in- 
clined to  regard  this  form  of  application  as  too  severe  for  most  patients. 

I  have  often  obtained  a  complete  restoration  of  muscular  power  in 
special  nerve-trunks  by  static  sparks  alone  after  the  "  reaction  of  degen- 
eration "  was  fully  developed  and  all  faradaic  excitability  had  ceased. 

Eighth. —  Cases  which  exhibit  a  marked  impairment  of  sensation 
(whether  of  touch,  pain,  or  temperature)  are  generally  improved,  in  my 
experience,  by  the  use  of  static  sparks  over  the  anaesthetic  area  more 
rapidly  than  by  the  faradaic  or  galvanic  currents. 


710  LECTUKES  ON  NEKVOUS  DISEASES. 

I  have  encountered  several  very  striking  cases  which  illustrate  this 
point  admirably,  but  a  lack  of  space  precludes  the  insertion  of  their 
histories. 

2^inth. — Remarkable  etfects  of  static  sparks  upon  that  form  of  bald- 
ness known  as  the  so-called  '■'■ivory  spots,^^  or  alopecia  arieta,  have  been 
observed  by  myself  through  the  courtesy  of  my  friend  Dr.  F.  B. 
Carpenter,  of  New  York.  I  have  seen  several  of  his  cases  where  he  has 
wrought  a  wonderful  change  in  the  appearance  of  the  scalp  after  several 
months  of  treatment  of  the  bald  spots  by  the  "  direct  "  spark.  The 
growth  of  the  hair,  which  had  apparently  been  totally  destro3'ed  over 
the  affected  regions,  is  attributable  probably  to  the  rekindling  of  the 
circulatory  and  nutritive  conditions  of  the  affected  area  upon  the  scalp. 

Tenth. — As  a  general  tonic  and  also  as  a  stimulant  to  depressed 
nervous  functions,  ^'■static  insulation''^  (Fig.  180)  seems  to  be  particu- 
larly of  service. 

I  employ  static  electricity  constantly  b}'  this  method  in  neurasthenia, 
with  marked  benefit. 

I  have  observed  also  remarkable  improvement  in  disturbed  visceral 
functions  (such,  for  example,  as  dyspepsia,  habitual  constipation, 
diabetes,  vertigo,  asthma,  etc.)  after  the  use  of  static  insulation  for  from 
ten  to  twenty  minutes  at  a  sitting. 

Man}^  such  cases  have  expressed  to  me  the  greatest  delight  at  the 
beneficial  eflfects  which  such  an  application  invariably  produced.  For 
the  past  three  years,  I  have  used  my  static  machine  almost  exclusively 
as  a  means  of  improving  the  "  general  nervous  tone  "  of  patients,  in 
preference  to  my  faradaic  or  galvanic  apparatus.  It  is  much  more 
satisfactory  to  patients  because  of  its  ease  of  application  ;  and,  as  far  as 
I  have  observed,  equally  effective  as  a  tonic. 

Eleventh. — I  am  inclined  to  think  that  those  authors  who  have 
written  upon  static  electricity  as  a  therapeutical  agent  in  a  lukewarm 
spirit  have  probably  been  supplied  with  an  apparatus  which  has  been 
ineffective  because  it  generated  too  slowly  or  imperfectly. 

The  size  and  number  of  the  revolving  plates  and  their  thorough 
protection  from  atmospheric  changes  are  factors  of  the  greatest  import- 
ance. 

As  I  have  already  said,  many  of  the  static  machines  sold  to  the 
profession  are  hardly  more  than  mere  toys.  Any  machine  which  gives  a 
thin  spark  (even  if  a  long  one)  lacks  one  essential  factor  to  success  as  a 
therapeutical  ngent,  namely,  quantity. 

Twelfth. — I  have  used  static  insulation  and  sparks  with  satisfaction 
in  the  treatment  of  ch ronic  infiammatory  and  spasmodic  di.^eases;  such, 
for  example,  as  infiuenza,  phthisis,  bronchitis,  ashthma,  laryngitis,  neu- 
ritis, synovitis,  etc. 


STATICAL   ELECTEO-THEEAPEUTICS.  711 

Three  cases  of  chronic  synovitis  of  the  knee-joint  of  an  intractable 
form  recovered  completely  under  my  care  within  a  month,  under  the 
daily  administration  of  static  sparks  to  the  affected  joint. 

Many  cases  of  bronchitis  and  asthma  have  been  greatly  benefited  b}' 
insulation  and  sparks  to  the  chest. 

I  have  used  static  insulation  (followed  b3'  the  withdrawal  of  sparks 
from  the  spine  and  abdomen)  upon  subjects  atliicted  with  dyspepsia, 
flatulency,  and  constipation.  In  many  instances  this  form  of  electrical 
ti'eatment  gave  very  marked  relief. 

The  influence  of  this  agent  upon  visceral  derangement  is,  however, 
a  field  for  future  investigation.  It  gives  promise  of  happy  results.  As 
yet,  my  personal  experience  is  too  limited  to  justify  me  in  formulating 
any  positive  conclusions  respecting  the  method  which  is  best  employed 
in  individual  cases. 

Thirteenth. — Static  electricity  is  of  value  in  the  treatment  of  hys- 
terical states  and  other  allied  conditions. 

Charcot  has  long  been  an  advocate  of  this  therapeutical  agent  in 
such  cases.  M}'  own  experience  teaches  me  that  it  is  of  great  service  as 
an  aid  to  recovery ;  although  I  believe  that  in  a  very  large  proportion 
of  these  subjects  reflex  irritation  from  "  eye-strain  "  has  to  be  combated 
In'  the  relief  of  anomalies  in  the  eye  or  its  muscles  before  a  perfect 
restoration  of  health  can  be  attained.  I  have  discussed  this  field  else- 
where. (See  New  York  Medical  Journal,  February',  1886,  and  April, 
188T.) 

In  closing,  I  would  state  that  the  length  of  this  article  (already  too 
prolonged,  perhaps)  precludes  the  insertion  of  the  histories  of  many 
typical  cases  which  would  be  of  great  interest  in  this  connection.  To 
fairly  illustrate  the  subject  in  its  many  ramifications  a  verj-  large  number 
of  lengthy  records  would,  however,  be  required. 

Medical  literature  within  the  past  ten  j^ears,  and  antiquated  works, 
also,  fairly  teem  with  cases  reported  hy  leading  men  in  the  profession 
here  and  abroad,  which  illustrate  their  concui'rence  and  firm  belief  in  the 
views  expressed  in  preceding  pages. 

Static  electricity  is  to-day,  for  the  second  time,  generally  recognized 
by  the  profession  as  a  valuable  therapeutical  agent.  Most  of  the  leading 
neurologists  have  now  a  Holtz  induction  machine  as  a  part  of  their  otiice 
equipment. 

The  later  editions  of  recognized  works  upon  electricity  as  applied 
to  medicine  show  almost  without  exception  that  this  variety  of  elec- 
tricity is  deemed  worthy  of  more  attention  than  it  received  in  the  earlier 
editions.  It  has  passed  through  its  stage  of  neglect  and  distrust  safely. 
It  is  steadily  regaining  the  popularity  it  so  justly  achieved  in  the 
eighteenth  century. 


712  LECTURES   ON   NERVOUS   DISEASES. 

SPECIAL   ELECTRO-THERAPEUTICS. 

We  have  thus  far  discussed  the  various  methods  of  employing  elee- 
tricitv  in  a  general  way,  and  tliere  remains  for  us  to  consider  how  we 
sliall  proceed  in  employing  this  agent  when  special  organs  are  diseased. 
I  would  i^reface  my  remarks  upon  this  field  with  the  statement  that  the 
curative  properties  of  electricity  must,  of  necessity,  he  modified  I13'  the 
pathological  conditions  which  exist  in  each  individual  case.  The  prog- 
nosis is  naturally  more  grave  in  some  conditions  than  in  others. 

For  example,  a  patient  wlio  has  motor  paralysis  which  is  due  to 
degenerative  changes  in  the  cells  of  the  anterior  horns  of  the  spinal  gray 
matter  will  not  usually  recover  the  power  of  motion  completely,  while  he 
ma}^  do  so  if  the  paralysis  be  due  to  a  cerebral  or  spinal  lesion  which  is 
not  accompanied  by  degenerative  nerve-changes.  Again,  all  forms  of 
functional  nervous  derangements  are  more  amenable  to  electrical  treat- 
ment (if  judiciously-  emplo^'ed)  than  are  the  graver  results  of  organic 
disease  of  the  nerve-centres.  A  muscle  which  has  atrophied  from  disuse 
can  usually  be  restored,  while  one  which  has  wasted  from  imperfect 
nutrition  (resulting  from  a  degenerated  nerve)  may  possibly  withstand 
all  efforts  to  improve  it.  The  therapeutical  use  of  electricity  is  subject 
to  the  same  influences  as  that  of  any  other  remedial  agent,  and  the 
prognostic  conditions  are  not  alwaj's  the  same  even  among  cases  of  the 
same  nature. 

In  previous  pages  I  have  given  many  hints  relating  to  the  differential 
diagnosis  which  you  will  be  called  upon  to  make  in  nervous  diseases,  and 
enough  has  been  said  in  reference  to  the  anatomy  and  physiology'  of  the 
nervous  system  to  assist  you  in  properly  interpreting  abnormal  nervous 
phenomena.  I  shall  therefore  give,  in  closing,  directions  only  as  to  how 
to  employ  electric  currents  upon  different  parts  of  the  body  without 
entering  to  any  extent  into  the  causation  of  the  symptoms  which  jou 
will  be  called  upon  to  treat.  Remember,  however,  that  accuracy  of 
diagnosis  is  the  basis  of  cure  in  a  large  proportion  of  cases. 

ELECTRICITY  IN  CEREBRAL  AFFECTIONS. 
Experiment  has  shown  beyond  dispute  that  galvanic  currents  can 
be  made  to  pass  through  the  substance  of  the  brain  when  inclosed  within 
the  skull.  It  is  much  less  certain  whether  the  same  may  be  said  of  fara- 
daic  or  static  currents.  The  beneficial  results  which  are  obtained  b3'the 
two  latter  (and  possibl}'  man}'  of  the  efiects  of  galvanism  as  well)  upon 
cerebral  diseases  are  to  be  attributed,  in  m}'  opinion,  chiefly  to  the 
alterations  produced  in  tiie  blood-supply  of  the  brain.  Some  of  the  most 
remarkable  results  ol)tained  by  neurologists  from  the  employment  of 
electricity  upon  the  head  itself  or  the  cervical  ganglia  of  the  sjunpathetic 


I 


ELECTRICITY   IN    CEREBRAL   AFFECTIONS.  713 

are  unquestionably  due  to  an  alteration  produced  in  the  calibre  of  the 
cerebral  vessels.  I  have  never  been  convinced  that  organic  lesions  of 
the  brain  can  be  cured  by  the  direct  use  of  this  agent  on  that  organ. 
On  the  other  hand,  I  am  fully  satisfied  that  the  S3'niptonis  of  cerebral 
hyperjvraia  and  auffimia  are  directly  influenced  b}^  galvanism  and  static 
electricity.  I  believe  that  any  unprejudiced  mind  can  be  readily  con- 
vinced of  the  scientific  accuracy  of  this  conclusion.  I  have  treated 
many  patients  (who  gave  undisputable  evidences  of  basilar  h3peraemia 
by  the  deflections  of  the  needle  of  a  calorimeter),  and  have  brought 
tiiem  to  a  state  of  perfect  health  within  the  space  of  a  few  weeks  by 
galvanism  of  the  head.  The  calorimeter  confirmed  the  cure  in  these 
cases  by  the  absence  of  deflection,  which  existed  before  treatment  was  com- 
menced. In  some  instances  of  this  condition,  static  electricity  proves  a 
very  valuable  adjunct  to  galvanism.  I  will  give  in  detail  a  few  of  the 
methods  which,  in  my  experience,  may  be  employed  in  cerebral  diseases 
with  a  prospect  of  great  benefit  to  the  patient. 

Cerebral  Hyperemia. — First  ascertain  b}^  means  of  a  calorimeter 
the  situation  and  extent  of  the  congestion.  Test  all  parts  of  the  head. 
When  necessary,  do  so  by  separating  the  hair  and  bringing  the  poles  as 
closely  as  possible  in  contact  with  the  scalp.  It  is  not  necessary,  as  a 
rule,  to  shave  the  head.  In  case  very  accurate  observations  are  demanded, 
this  step  may  have  to  be  taken, — as,  for  example,  when  a  cerebral  tumor 
is  suspected  to  exist. 

At  the  nape  of  the  neck,  over  the  mastoid  processes,  upon  the 
temples,  and  over  the  forehead,  no  hair  exists  to  interfere  Avith  the  deter- 
mination of  the  relative  temperament  of  the  two  sides,  or  of  different 
regions  of  the  corresponding  side.  The  calorimeter  will  aid  you  in  diag- 
nosis and  treatment ;   if  properly  used,  it  is  sometimes  invaluable. 

The  following  are  the  steps  in  treatment  most  generallv  useful : — 

(1)  Apply  the  cathode  to  the  nape  of  the  neck,  close  to  the  skull, 
and  the  anode  over  the  forehead.  Make  stabile  applications  for  one  or 
two  minutes  to  each  side  of  the  forehead,  the  cathode  remaining  stabile. 
(2)  Make  labile  anodal  applications  to  the  forehead  transversely  for  owe 
minute.  (3)  Move  the  cathode  to  the  mastoid  region  of  each  side,  place 
the  anode  centrally  on  the  forehead,  and  continue  each  stabile  applica- 
tion for  fro7n  thirty  seconds  to  one  minute.  This  may  make  the  patient 
dizzy.  (4)  Do  not  use  a  current  which  produces  pain  to  the  patient,  but 
have  as  great  intensity  as  he  can  comfortably  bear.  (5)  Never  reverse 
the  current  when  the  poles  are  on  the  head. 

These  applications  may  daily  be  alternated  with  "  insulation  "  and 
the  '•''electric  head-bath,''''  if  you  possess  a  static  machine.  The  sittings 
should  occur  daily  until  the  symptoms  are  cured  and  the  calorimeter 
ceases  to  show  its  previous  deflection. 


714 


LECTURES  ON  NERVOUS   DISEASES. 


It  is  sometimes  well  to  stimulate  the  superior  cervical  ganglion  by 
placing  jv  small  anode  in  the  fossa  behind  the  angle  of  the  jaw,  and  the 
cathode  on  the  seventh  cervical  spine,  and  to  slowly  interrupt  the  current. 
Caution  must  be  exercised  against  employing  too  strong  currents. 

Finall}^,  active  faradization  of  the  limbs  is  sometimes  necessary,  in 
order  to  draw  the  blood  to  the  limbs.  It  is  not  well  to  employ  this  step 
if  it  causes  an  elevation  of  tempei-ature. 

The  effects  of  this  treatment  should  be  to  relieve  the  pain  or  sense  of 
fullness  in  the  head,  the  vertigo  on  rising,  the  mental  confusion  or  distress, 
the  insomnia,  and  the  many  other  symptoms  peculiar  to  this  condition; 
and  to  steadily  reduce  the  calorimeter  detlections  when  the  poles  are  in 
contact  with  homologous  parts. 


Fig.  189. — A  Schematic  Repkesentation  ofthe 
Distribution  of  an  Electric  Current  ap- 
plied Unilaterally  through  the  Head. 
(After  Erb.)  The  anode  (  +  )  rests  above  the 
ear  of  the  left  side.  The  cathode  ( — )  is  sup- 
posed to  be  at  the  nape  of  the  neck,  and  to  exert 
its  influence  as  far  as  the  line  drawn  horizontally 
across  the  neck. 


Fig.  190. — A  Schematic  Representation  ofthb 
Course  of  Electric  Currents  sent  Trans- 

VERSELY    THROUGH    THB  HeAI).         (.After    Erb.) 

The  cathode  { — )  is  represented  as  placed  on 
the  same  side  as  the  lesion. 


Cerebral  Anaemia. — -I  should  advise  you  to  begin  the  use  of  very 
weak  galvanic  currents  after  an  attack  of  embolism.  I  believe  that  cur- 
rents of  this  kind  sent  transversely  through  the  head  from  the  temples, 
and  occasionally  in  the  antero-median  plane,  assist  in  absorbing  the  col- 
lateral oedema  and  cause  a  diminution  of  the  collateral  h3'pera3mia.  I 
prefer  to  use  the  cathode  on  the  side  of  the  embolic  obstruction  when 
transverse  currents  are  employed.  In  my  opinion,  it  tends  to  promote 
absorption  and  to  contract  the  vessels  far  more  than  the  anode.  The 
paralyzed  muscles  should  be  treated  separately,  by  methods  given  in 
detail  later. 

Some  four  years  ago  Lowenfeld  published  some  deductions  relative  to 
the  action  of  galvanic  currents  upon  the  brain,  based  upon  experimental 
researches.  Although  their  accuracy  has  been  justly  called  in  (question 
by  authors  of  note,  my  own  experience  leads  me  to  confirm  them  in  part 


ELECTRICITY   IN   CEREBRAL   AFFECTIONS.  715 

and  to  attach  some  importance  to  them.  These  conclusions  were  as  fol- 
low: (1)  anode  at  forehead  and  cathode  at  neck  cause  contractions  of 
the  vessels  of  the  pia ;  (2)  anode  at  neck  and  cathode  at  forehead  cause 
dilatation  of  the  vessels  of  the  pia ;  (3)  when  transverse  currents  are 
enipIo3'ed,  the  cathode  causes  contraction  of  adjacent  vessels,  and  the 
anode  dilatation. 

When  cerebral  ansemia  of  a  general  chai'acler  exists  (as  a  manifesta- 
tion of  poverty  of  the  blood,  defective  heart-power,  etc.),  general  ftira- 
dization,  central  galvanization,  and  static  electricity  by  insulation  are 
often  of  material  benefit.  Tlie  removal  of  the  cause  by  judicious  medi- 
cation, etc.,  is,  of  course,  vital  to  successful  electrical  treatment. 

Hemiplegia  of  Cerebral  Origin. — A  ver}^  lai'ge  proportion  of  pa- 
tients with  hemiplegia  from  cerebral  causes  OAve  the  paral3'sis  of  their 
limbs  to  hemorrliage,  softening,  or  embolism.  The  electrical  treatment 
should  be  directed  to  both  the  brain  and  the  muscles.  It  should  not  be 
commenced  (save  in  the  case  of  embolism  or  thrombosis)  until  a  month 
has  elapsed  since  the  attack.  Each  patient's  susceptibility  to  the  agent 
should  be  carefully  studied,  and  the  strength  of  current  employed 
should  be  modified  accordingl3\  The  muscles  ma}-  be  treated  b}-  faradi- 
zation or  galvanization,  or  b}'  the  static  current  (indirect  sparks  being 
drawn  from  the  paralyzed  limbs).  The  brain  should  be  subjected  to 
galvanization  onl}-,  or  to  static  insulation. 

If  the  patient  fails  to  show  improvement  within  a  month  after  the 
treatment  has  been  dail}-  applied,  or  if  the  improvement  of  the  first  few 
days  is  rapidly  lost  in  spite  of  continued  treatment,  the  prognosis,  as 
regards  marked  amelioration  of  the  paralysis  b}'  electrical  applications, 
is  grave. 

HemiaNv^sthesia  is  best  treated  b}'  the  wire  brush  upon  tlie  dr^-  skin 
in  connection  with  the  secondary  faradaic  current.  I  have  also  obtained 
some  remarkable  effects  with  the  combined  current  (as  before  stated), 
and  also  with  the  static  current,  in  cases  where  the  faradaic  current  was 
ineffective. 

PosT-PARALYTic  RiGiDTTY  (occurring  late)  is  the  result,  in  most  cases, 
of  secondary  changes  within  the  spinal  cord.  The  supervention  of  pig- 
mentation of  the  nails,  oedema,  a  shiny  skin,  disease  of  the  joints,  and 
other  evidences  of  trophic  alterations,  points  to  a  serious  and  often  per- 
manent destruction  of  the  nerve-centres. 

Hints  which  have  been  given  under  the  head  of  general  electro- 
therapeutics will  guide  j'ou  in  modifying  the  treatment  according  to  the 
exigencies  of  each  individual  case.  Tlie  remarkaV)le  improvement  which 
some  hemiplegics  obtain  through  the  instrumentality  of  electrical  treat- 
ment shouUl  impress  you  with  the  necessity  of  employing  it  long  enough 
to  ascertain  whether  its  continued  use  is  indicated. 


716 


LECTURES   ON  NERVOUS   DISEASES. 


Monoplegia  or  Monospasm. — These  conditions  are  particularly  in- 
dicative of  cortical  disease.  The  muscles  aflected  are  a  guide  to  the 
convolution  attacked.  I  have  covered  this  field  in  a  previous  section. 
The  indication  in  such  a  case  is  to  improve,  if  possible,  the  nutrition  of 
the  diseased  part  directlj'  by  galvanism,  and  also  to  stimulate  the 
muscles  functionally  associated  with  it.  1  employ  for  this  purpose  a 
"medium  "  electrode  over  the  diseased  convolution,  the  indiHerent  elec- 
trode being  placed  over  the  centre  of  the  sternum.  It  is  my  custom  to 
employ  both  poles  separately  to  the  head  for  an  interval  of  two  minutes 
each  at  a  sitting.  The  monoplegic  limb  may  be  treated  by  la1)ile  galvanic 
applications,  the  wire  brush  and  ftiradization,  or  the  indirect  spark  by 
means  of  a  static  machine. 

Duchenne's  Disease. — The   morbid  changes  in    the   nuclei  of  the 


Fig  191  — A  Schematic  Representation  of  the  Distribution  and  Density  of  the 
Thkeaos  of  Current  with  regard  to  their  Entranck  into  the  Spinal  Coru. 
(After  Erb.)  In  rt  the  poles  are  placed  near  each  other.  In  li"  the  poles  are  more  widely 
separated.  The  size  of  the  electrodes  shown  in  the  cut  is  the  same  for  both  the  anode  and 
cathode. 

medulla  which  accompany  bulbar  paralysis  may,  in  some  cases,  be  held 
in  check  for  a  while  and  the  symptoms  markedly  improved  b}'  placing 
the  positive  electrode  (of  large  size)  at  the  nape  of  the  neck  and  as 
close  as  possible  to  the  foramen  magnum,  and  appl3'ing  the  negative 
electrode  (covered  with  absorbent  cotton  and  attached  to  a  long  handle) 
successively  to  the  pharynx,  fauces,  tongue,  cheeks,  and  lips.  As  strong 
a  current  as  the  patient  can  easily  endure  should  be  used.  The  duration 
of  the  sitting  should  not  exceed  five  minutes.  It  is  well  to  complete  the 
sitting  by  passing  transverse  currents  through  the  neck,  so  as  to  excite 
the  muscles  concerned  in  deglutition.  Some  authors  recommend  the 
employment  of  currents  through  the  head,  both  longitudinally  and  trans- 
versely. 


ELECTRIZATION   OF   THE   SPINAL    CORD. 


717 


ELECTRICITY   IN   SPINAL   AFFECTIONS. 

Tliere  are  various  ways  of  bringing  the  spinal  cord  under  tlie 
influence  of  electrical  currents.  The  method  of  application  selected  in 
any  individual  case  will  depend  somewhat  upon  the  sj-mptoms  whicli  the 
patient  presents,  and  also  upon  tlie  character  and  seat  of  the  lesion. 
The  diagrammatic  cuts  of  Erb,  which  illustrate  the  diffusion  of  electrical 
currents,  show  in  a  graphic  way  the  effects  of  close  approximation  and 
wide  separation  of  the  poles.  We  ma}-  also  modify-  some  of  the  morbid 
conditions  of  the  spinal  cord  by  electrization  of  the  extremities  when  the 
indifferent  pole  is  placed  over  spinous  processes.  It  is  well  to  increase 
the  size  of  the  electrodes  proportionately  to 
the  strength  of  the  current  employed. 

Fig.  191  illustrates  the  effect  of  separation 
of  the  poles  when  applications  of  electricity 
are  made  to  the  spinal  column.  Some  of  tlie 
threads  of  current  depicted  are  rendered  in- 
effjective  on  account  of  their  diffusion.  This 
is  made  more  apparent  in  Fig.  192. 


Fig.    192 — A    Schematic    Repre- 
sentation  OP   THE   Density   of 

THE  CUKRENT    UPON  APPLICATION 

OP  THE  Electrodes  to  the  Same 
Surface  and  in  Close  Relation 
TO  each  other.  (After  Erb.) 
The  dotted  lines  indicate  the  in- 
effective threads  of  current.  The 
shaded  portion  represents  the  zone 
of  greatest  intensity. 


.ho 


ELECTRIZATION   OF   THE   SPINAL   CORD. 

To  treat  properly  of  the  various  methods 
which  may  be  used  when  the  application  of 
electrical  ciu'rents  as  a  therapeutical  measure 
for  the  relief  of  spinal  diseases  seems  indicated, 
it  would  be  necessary  for  me  to  enter  into 
greater  detail  regarding  s])inal  diseases  than 
the  space  allotted  to  these  lectures  will  perjiiit 
of.  I  am  reluctantly  forced,  therefore,  to 
summarize  somewhat  hastily  the  main  points 
which  my  experience  with  this  agent  leads  me 
to  indorse.  Most  of  my  readers  are  probably 
already  familiar  with  the  pathological  changes  which  exist  in  connection 
with  the  more  common  diseases  of  the  cord  ;  but,  if  any  are  not  so,  these 
changes  should  first  be  studied  and  thoroughly  mastered  before  the}-  can 
hope  to  successfully  combat  them. 

Galvanic  currents  are  of  greater  service  in  the  treatment  of  spinal 
diseases  than  faradaic  or,  perhaps,  the  static, — chiefly  on  account  of  the 
tlepth  of  the  tissues  affected  and  the  chemical  and  molecular  changes 
which  galvanic  currents  tend  to  induce. 

Spinal  electrodes  should  be  of  large  size. 

The  applications  may  be  either  stabile  or  labile,  the  former  being  of 
the  greatest  benefit  when   the  spinal  lesion  is  circumscribed  in  extent, 


718  LECTURES   ON  NERVOUS  DISEASES. 

and  the  latter  when  a  laroer  part  of  the  spinal  cord  is  artected.  If  lahile 
applications  are  indicated,  the  movements  of  the  electrodes  should  be 
made  somewhat  slowly. 

In  directing  galvanic  currents  to  the  cervical  and  upper  dorsal  seg- 
ments of  the  cord,  it  is  well  to  place  one  electrode  of  medium  size 
behind  and  below  the  ear  alternately  on  the  two  sides  of  the  neck,  while 
the  other  is  applied  to  the  spine. 

Points  of  tenderness  to  pressure  along  the  spine  should  be  subjected 
to  stabile  ni)i)lications  of  the  anode.  Thev  should  be  sought  for  in  each 
individual  case  with  care  and  separately  galvanized. 

The  strength  of  the  currents  employed  should  be  modified  in  indi- 
A'iduals  b}-  the  condition  which  is  presented  for  treatment.  Weak  cur- 
rents of  from  two  to  five  milliamperes  act  best,  as  a  rule,  when  excessive 
irritability  of  the  organ  exists ;  chronic  pathological  conditions  respond 
better  to  currents  of  greater  intensity.  1  often  use  eight  to  twelve 
milliamperes  of  current  in  chronic  cases. 

It  is  advantageous,  in  some  subjects,  to  make  electrical  applications 
to  the  limbs  when  the  cord  is  affected.  Stimulation  of  the  peripheral 
nerves  and  the  muscles  connected  with  the  segments  of  the  cord  involved 
should  be  particularly  aimed  at,  although  the  electrization  of  the  skeletal 
muscles  and  the  skin  should  not  be  exclusivel}'  confined  to  the  limits  thus 
indicated.  It  is  my  custom  to  employ  the  '•  combined  current "  (previ- 
ousl}'  described)  when  applications  to  the  limbs  are  thus  made.  This 
form  of  current  is  particularly  indicated  when  the  muscles  exhibit  a  ten- 
dency toward  atroph}-.  The  electrode  which  rests  upon  cervical  or  lum- 
bar enlargements  of  the  s})ine  should  be  of  large  size,  while  that  used 
upon  the  limbs  should  be  of  medium  size,  so  as  to  direct  the  combined 
currents  to  the  nerves  or  muscles  affected. 

If  galvanism  alone  is  ^^sed  upon  the  limbs  in  spinal  disease,  it  is 
often  beneficial  to  the  patient  to  break  the  current  bv  an  interrupting 
electrode,  or  to  reverse  its  direction  by  means  of  the  commutator. 

Some  authorities  advocate  faradization  of  the  vertebral  region  and 
of  the  limbs  in  conjunction  with  galvanic  applications.  I  have  seen,  in 
a  few  instances,  some  remarkable  effects  follow  the  employment  of  the 
wire  brush  alone  in  poliom^-elitis  of  children,  and  I  can  see  no  reason 
to  doubt  its  occasional  efticac}^  in  other  forms  of  spinal  disease. 

In  some  unexplained  way  the  excitation  of  muscular  action  and 
stimulation  of  the  cutaneous  nerves  exert  in  many  instances  a  remedial 
effect  upon  lesions  of  the  spinal  cord. 

It  is  not  always  possible  (as,  for  example,  in  poliomyelitis)  to  excite 
muscular  action  by  faradaism  alone.  In  these  cases  interrupted  galvanic 
currents,  or  the  "combined  current"  (galvano-faradaic),  will  accomplish 
the  desired  end,   I  have  repeatedly   observed  beneficial  effects  of  this 


ELECTRICITY  IN   PARALYSIS   OR  PARESIS.  719 

treatment  in  locomotor  ataxia,  and  Knmpf  has  published  some  eases 
which  sustain  this  view  in  which  the  wire  brush  was  used  upon  the  arms 
and  legs  daily  for  about  five  minutes. 

In  all  acute  inflammatory  disorders  of  the  cord  I  deprecate  the  use 
of  electrical  applications.  M'^hen  the  acute  stage  has  passed,  or  when 
the  disease  has  assumed  a  chronic  type,  many  of  the  etiects  of  the  dis- 
ease (as,  for  example,  muscular  paralysis,  rectal  or  vesical  complications, 
incipient  caries,  anaesthesia,  etc.)  may  often  be  greatly  relieved  by  its 
judicious  nse.  The  current-strength  employed  in  such  cases  usually 
varies  from  five  to  eight  niilliamperes.  The  applications  should  be  made 
daily.  When  possible,  it  is  important  that  the  reader  localizes  early  the 
seat  of  the  structural  lesion  and  concentrates  the  treatment,  for  a  while 
at  least,  upon  the  segments  of  the  cord  involved.  The  muscles,  skin, 
bladder,  rectum,  etc.,  should  be  separately  subjected  to  the  influence  of 
electricity  in  case  tlie}^  exhibit  a  loss  of  function. 

ELECTRICITY   IN   PARALYSIS   OR   PARESIS. 

Hypokinesis  may  be  due  to  many  different  conditions  ;  hence,  its 
electrical  treatment  and  prognosis  must  vary  in  accordance  with  the 
cause  which  excites  it.  You  should  remember  that  paralysis  of  a  muscle 
is  only  symptomatic  of  other  conditions, — such,  for  example,  as  lead- 
poisoning,  diphtheria,  hysteria,  mechanical  pressure  upon  a  motor  nerve, 
severance  of  a  motor  nerve,  destructive  processes  or  inflammation 
within  the  motor  cells  of  the  brain  or  spinal  cord,  and  changes  in  the 
vessels.  All  of  these  tend  to  impair  either  the  generating  power  of  a 
motor  centre,  or  the  conducting  i)ower  of  a  motor  fibre. 

Respecting  the  application  of  electricity  to  the  seat  of  central 
lesions  (i.e.,  lesions  of  the  brain  or  spinal  cord)  in  cases  of  motor 
paralysis,  De  Watteville  pertinently  remarks  as  follows  : — 

"  It  is  true  that  we  have  too  often  but  a  very  imperfect  idea  of  those 
processes  in  the  nerve-centres  upon  which  the  symptom  depends,  and 
that  we  have  no  right  to  assume  that  the  current  has  a.ny  specific  cura- 
tive influence  upon  any  one  of  them  ;  still,  as  a  justification  for  central 
treatment  in  such  cases,  we  may  plead  our  very  ignorance,  Ave  may  urge 
the  poverty  of  our  therapeutical  arsenal  in  arms  wherewith  to  combat 
our  enemy,  and  may  also  invoke  the  possibility^  of  at  least  staying  its 
progress  by  promoting  nutrition  of  the  surrounding  portions  of  the 
nervous  structures  threatened  b}^  its  invasion." 

When  the  lesion  directly  afliects  the  conductivity  of  a  nerve,  we 
have  reason  to  believe  that  the  direct  influence  of  electrical  currents  upon 
the  lesion  tends  to  overcome  the  resistance  offered  to  conduction  b}'  the 
disease-process,  and  facilitates  the  subsequent  transmission  of  voluntary 
stimuli. 


720  LECTURES  ON  NERVOUS  DISEASES. 

There  arc  certain  jreneral  rules  that  are  applicable  to  the  electrical 
treatment  of  paralysis  of  motility.     These  may  be  stated  as  follows  : — 

1.  The  treatment  should  not  be  alone  confined  to  the  region  of  the 
paralyzed  muscles. 

2.  The  seat  of  the  exciting  lesion  should  be  ascertained  earh',  if 
possible,  and  subjected  to  the  influence  of  this  therapeutical  agent  in  an 
intelligent  way. 

3.  If  the  motor  paralysis  is  accompanied  by  anaesthesia,  hypernes- 
thesia,  or  other  sensory  disturbances,  or  if  the  vaso-motor  S3'stem  of 
nerves  be  apparently  implicated,  the  wire  brush  may  often  be  used  with 
advantage  upon  the  skin  in  the  vicinit}-  of  the  lesion,  and  also  over  the 
muscles  paralyzed. 

4.  Faradaic  currents  (provided  they  excite  muscular  action),  or  the 
cathode-pole  of  a  galvanic  battery  (with  interruptions  of  the  current),  are 
of  use  in  exciting  the  conductivity  of  the  nerve-tracts  aflected.  Static 
electricit}'  is  also  of  great  utility  in  inducing  muscular  contractions,  and 
is  generally  less  painful  than  strong  faradaism  or  galvanic  shocks. 

5.  The  "  combined  current  "  (galvano-faradaic)  is  chiefly  of  service 
in  overcoming  trophic  disturbances,  which  often  manifest  themselves  in 
connection  with  motor  paralysis. 

6.  I  prefer  labile  applications  to  stabile  in  applying  either  faradaism 
or  galvanism  to  the  muscles.  Stabile  applications  are  preferable  to 
labile  when  the  brain,  spinal  cord,  or  peripheral  nerve-trunks  are  to  be 
influenced. 

7.  Never  begin  the  use  of  electricity  immediately  after  the  onset  of 
paralysis  (wiien  due  to  a  central  lesion).  It  is  always  best  to  wait  until 
all  danger  of  exciting  a  recurrence  of  the  attack  bj'  stimulation  of  the 
nerve-centres  has  passed. 

ELECTRICITY   IN   SPASMODIC   AFFECTIONS. 

Hj'perkinesis  is  frequently  encountered  as  one  of  the  varied  forms 
of  external  manifestation  of  irritative  and  destructive  lesions  of  the 
central  nervous  system.  For  example,  it  is  by  no  means  uncommon  to 
observe  convulsions  (of  the  clonic  or  tonic  type),  tremor,  muscular 
rigidity  and  contracture,  etc.,  in  connection  with  morbid  changes  in  the 
brain  and  spinal  cord.  By  these  symptoms  we  are  often  assisted  in  deter- 
mining the  seat  of  the  lesion,  although,  as  De  Watteville  remarks,  "  the 
pathogeny  of  spasm  is  one  of  the  most  obscure  problems  in  neurology." 
On  the  other  hand — as,  for  example,  in  many  instances  of  chorea, 
epileps}',  hysteria,  etc. — spasm  may  exist  without  any  apparent  structural 
changes  in  the  nervous  system  ;  being  excited  by  some  source  of  reflex 
irritation,  such  as  visu.al  defect,  phimosis,  uterine  displacement,  insuf- 
ficienc}^  of  the   ocular  muscles,  etc.      In  tetanus  the  exciting  cause  is 


I 


ELECTRICITY   IN    SPASMODIC   AFFECTIONS.  721 

<2;iMUM:illy  found  in  one  or  more  of  tlie  perii)lieral  nerves.  Sclerosis  of 
the  motor  (ibres  of  tlie  latenil  columns  of  tlie  si)inal  cord  is  known  to 
produce  muscular  contracture  as  a  prominent  symptom,  probably  because 
the  iniiibitory  influence  of  the  brain  upon  tlie  reflex  excitabilit}'  of  the 
spinal  cord  is  arrested,  or  because  the  sclerosis  directl}'  excites  the  motor 
apparatus  of  the  cord.  The  peculiar  deformities  produced  by  post- 
paralytic contracture,  and  tlie  eccentricities  of  gait  and  posture  exhibited 
by  patients  sutt'ering  from  tetanoid  paraplegia  (lateral  spinal  sclerosis), 
are  illustrative  of  the  diagnostic  value  of  tonic  muscular  spasm  in  the 
course  of  some  spinal  afl[ections. 

Respecting  the  effects  of  electrical  treatment  of  spasm,  I  am  con- 
vinced that  in  some  cases  many  methods  must  be  tried  without  benefit 
before  the  right  one  is  discovered.  I  have  occasionally  had  brilliant 
results  follow  some  particular  method,  and  subsequently-  I  liaA'e  been 
utterly  disappointed  when  it  was  tried  upon  some  other  patient  with 
identical  symptoms. 

I  think  that  in  this  class  of  subjects  more  depends  upon  success 
in  ascertaining  and  removing  the  cause  than  upon  an}'  electrical  applica- 
tions (valuable  as  the}'  may  be  as  adjuncts).  The  correction  of  an  optical 
defect  by  glasses,  the  relief  of  ocular  insufliciency  by  tenotomy  or  prisms, 
the  operation  of  circumcision,  the  mechanical  relief  of  a  displaced  womb, 
the  removal  of  bad  teeth,  and  man}'  other  such  procedures,  form  the  basis 
of  an  absolute  cure  in  many  cases  which  have  been  otherwise  treated 
unsuccessfully.     This  fact  is  too  often  disregarded. 

Electrical  currents  maybe  made  to  act  upon  these  cases  (1)  as  a 
sedative  (chiefly  the  action  of  the  anode  and  static  insulation);  (2)  as  a 
stimulant  (the  action  of  the  cathode,  the  static  spark,  or  faradaism);  (.3) 
as  a  counter-irritant;  (4)  as  a  check  to  the  progress  of  some  peripheral 
or  central  morbid  state  (catalytic  action) ;  and  (5)  as  an  agent  for  the 
destruction  of  some  neoplasm,  induration,  etc.  (electrolytic  action),  or  as 
a  cautery. 

I  have  lately  come  to  regard  static  electricity  (franklinism)  as  more 
generally  applicable  to  spasmodic  conditions  (hysteria,  torticollis, 
l)lepharospasm,  tremor,  contracture,  etc.)  than  either  faradaism  or  galvan- 
ism. It  seems,  in  my  experience,  to  act  more  promptly,  and  to  produce 
more  lasting  results  than  the  methods  more  commonly  recommended  by 
authors.  I  would  advise  those  who  decide  to  purchase  a  static  machine 
to  try  the  effects  of  insulation,  the  "electric  wind,"  and  the  indirect 
spark  (as  the  circumstances  may  indicate)  faithfully  before  they  resort 
to  galvanization  or  faradization.  If  good  results  are  not  obtained,  they 
can  easily  substitute  for  it  the  other  forms  of  treatment  at  a  later 
dnte.  I  should  never  regard  any  case  as  hopeless  until  it  had  been  thor- 
oughly tried  (after  all  reflex  causes   had   been  removed^.     I  have  cured 

4« 


I 


722  LECTURES   ON   NEllVOUS   DISEASES. 

several  severe  cases  of  toiii(!  spasm  of  the  muscles  of  the  neck  in  a  few 
sittings  by  means  of  tlu;  indirec-t  spark,  and  relieved  many  cases  of  suf- 
fering from  other  forms  of  spasm  in  a  short  time. 

In  EPILEPSY,  the  employment  of  galvanism  alone  has  never,  to  my 
knowledge,  resulted  in  a  complete  cure,  although  some  decided  benefits 
have  been  reported  from  its  continued  use.  There  is,  to  m^^  mind,  a  close 
relationship  in  many  cases  between  epilepsy  and  ocular  defect^  to  which 
I  have  already  called  attention.  This  element  in  the  causation  of 
epilepsy  certainly  merits  attention.  When  all  defects  in  the  visual 
apparatus  have  been  corrected  (in  case  such  exist),  or  when  other  reflex 
causes  (such  as  phimosis,  for  example)  have  been  relieved,  galvanism  and 
static  electricity  may  become  valuable  aids  in  controlling  the  subsequent 
convulsive  attacks.  Latent  hyperopia,  astigmatism,  and  insutliciency  of 
any  of  the  muscles  of  the  eyeball  may  (and,  in  my  opinion,  often  do)  excite 
epileptic  seizures.  It  is  absurd  to  expect  of  electricity,  or  any  other 
therapeutical  agent,  curative  results  when  so  important  a  source  of  irrita- 
tion of  the  central  nervous  system  is  allowed  to  remain  uncorrected. 

Rockwell's  method  of  employing  "  central  galvanization  "  in  epilepsy 
does  not,  to  my  mind,  equal  in  beneficial  eti'ects  the  use  of  static  insula- 
tion and  the  drawing  of  indirect  sparks  from  the  neck  and  l)ack  of  the 
patient.  It  is  my  custom,  however,  in  some  cases  to  employ  both  of 
these  procedures,  each  being  used  alone  during  alternate  weeks  for  a 
period  of  two  or  three  months  with  daily  sittings. 

In  CHOREA  I  have  obtained  the  best  results  with  static  insulation 
and  sparks. 

My  previous  remarks  respecting  the  relationship  between  defects  in 
the  organ  of  sight  and  epilepsy  apply  with  equal  force  to  this  disease 
and  all  other  types  of  functional  nervous  derangements.  1  have 
discussed  this  subject  more  in  detail  when  functional  nervous  diseases 
were  being  considered. 

If  gaWanism  is  employed,  it  is  best  to  subject  the  muscles  affected 
with  spasm  to  the  action  of  the  anode.  The  prognosis  will  depend 
somewhat  upon  the  duration  of  the  disease.  The  earlier  you  begin 
electrical  treatment,  the  greater  is  the  prospect  of  cure  (provided  all 
sources  of  reflex  irritation  ha^e  been  successl'ully  removed). 

My  experience  with  faradaism  in  the  treatment  of  chorea  has  been 
somewhat  limited  ;  but  the  results  obtained  by  me  have  not  been  so 
satisfactory  as  with  static  electricity. 

In  FACIAL  SPASM  (liistrionic  spasm)  good  results  are  occasionally 
obtained  by  following  the  plan  of  treatment  suggested  in  connection 
with  chorea ;  but  treatment  of  the  facial  nerve  alone  is  seldom  satisfac- 
tory. I  have  one  case  at  present  under  treatment,  however,  in  which  I 
have  thus  far  had  little,  if  any,  success  in  m\'  attempts  to  control  the 


« 


ELECTRICITY   IN   SPASMODIC   AFFECTIONS.  723 

spasm.  It  is  a  case  of  long  standing,  and  is  therefore  more  rebellious  to 
troutment  than  if  it  were  not  chronic.  The  patient  has  an  ocular  defect 
which  it  is  difficult  to  correct  perfectl}'. 

In  these  cases  I  have  obtained  the  best  residts  by  subjecting  both 
the  cortical  centres  for  facial  movements  and  the  nerve  itself  to  stabile 
applications  of  the  anode  (the  catiiode  being  placed  on  the  breast-bone), 
and  by  treating  the  nerve  at  intervals  Avith  static  sparks  drawn  from  the 
affected  i)ortions  of  the  face.  The  electrode  for  the  head  should  be  large. 
The  duration  of  each  daily  sitting  should  not  exceed  five  minutes. 

Nystagmus  and  blepharospasm  belong  to  the  choreic  type  of  dis- 
eases, and  are  best  treated  b}'  electrical  currents,  provided  tliey  are  seen 
before  the  condition  has  become  chronic.  The  prospect  of  a  radical 
cure  steadily  becomes  less  as  time  elapses.  If  static  cui-rents  are  em- 
ployed, wooden  tips  to  the  electrodes  should  be  used.  I  usuall}'  treat 
these  cases  as  if  the  seventh  nerve  were  involved  in  all  of  its  branches. 
Sometimes  it  is  well  to  place  the  anode  upon  the  mastoid  process  and 
the  cathode  upon  the  closed  eyelid.  The  current  should  be  very  weak  at 
first;  should  be  gradually  increased  until  faint  flashes  of  light  are  per- 
ceived ;  finally,  it  should  be  again  decreased  to  the  faintest  perceptible 
point. 

Torticollis,  or  avry-neck,  when  subjected  earl^^  to  static  sparks  or 
strong  faradization,  ma}'  often  be  cured  very  rapidly.  Interrupted 
galvanic  currents  are  also  of  material  benefit  in  some  cases. 

The  spinal  accessory  nerve  is  usually  the  one  which  is  at  fault.  A 
rheumatic  origin  may  often  be  detected.  If  so,  judicious  medication 
will  tend  to  hasten  the  cure. 

Some  cases  of  wry-neck  are  associated  with  symptoms  of  paresis. 
These  have,  as  j^ou  might  suspect,  a  more  serious  prognosis.  Electrical 
treatment  will  prove,  as  a  rule,  only  palliative.  Too  often  organic 
changes  have  already  occurred  in  the  spinal  accessory  nerve,  the  spinal 
cord,  or  the  vertebra;.  The  duration  of  treatment  should  extend  over 
a  period  of  months. 

Spasmodic  asthma  may  often  be  benefited  by  galvanism  of  the  neck. 
I  have  previously  described  the  steps  of  this  procedure.  Its  beneficial 
efl'ects  are  probably  due  to  changes  induced  in  the  vagi.  Drawing  of 
indirect  sparks  (by  means  of  the  static  machine)  from  tlie  anterior  and 
posterior  surface  of  the  chest  has  proved,  in  my  experience,  an  admirable 
preventative  against  such  attacks. 

Some  patients  have  assured  me  that  they  experienced  a  sense  of 
great  comfort  after  each  sitting,  and  that  the  frequency  of  the  paroxysms 
of  asthma  has  been  perceptibly  modified  by  them.  My  experience  in 
the  electrical  treatment  of  these  cases  is  as  yet  somewhat  limited  ;  but  I 
am  inclined  to  believe  that  greater  benefit  can  be  derived  from  it  than 


724  LECTURES   ON   NERVOUS   DISEASES. 

from  internal  rnodifjition.  Certainly  it  is  worthy  of  a  more  extended 
trial  as  an  adjunct,  if  deemed  wise,  to  otiuM"  remedial  measures,  or  as  a 
substitute  for  them. 

In  TETANUS  (both  of  the  traumatic  and  idiopathic  varieties)  two  cases 
of  cure  have  been  rejjorted  by  Mendel,  of  Berlin.  lie  employed  galvani- 
zation and  subjected  the  muscles  affected  with  spasm  to  the  stabile  influ- 
ence of  the  anode,  the  cathode  resting  over  the  spinous  processes  of  the 
vertebrae.  The  applications  were  continued  for  fifteen  minutes,  and  the 
currents  employed  were  mild  ones.  Bartholow  suggests,  when  speaking 
of  these  cases,  that  the  effect  of  these  applications  was  probably  due  "  to 
the  influence  of  the  currents  upon  the  sensory  nerves,  thus  lessening  tiie 
intensity  of  the  reflexes."     The  cures  wxn-e  complete  in  about  ten  days. 

Personally,  I  have  not  as  yet  been  able  to  test  the  eflfects  of  the 
different  forms  of  electrical  currents  upon  a  case  of  tetanus.  To  my 
mind  it  would  be  very  interesting,  however,  to  observe  the  effect  of  static 
insulation  and  static  spai'ks  upon  the  si)asms  which  occur  jjaroxysmallv 
in  tills  disease.  It  is  well  known  that  this  agent  exerts  a  remarkable 
effect  upon  contracture  of  muscles.  Thus  far,  to  my  knowledge,  it  has 
never  been  tried  in  tetanus. 

Sneezing,  hiccough,  and  coughing  are  spasmodic  efforts  of  a  reflex 
character.  Occasionally  they  become  distressing  from  their  persistency. 
They  may,  in  some  instances,  be  relieved  by  f:xradization  of  the  epigas- 
trium, galvanization  of  the  neck,  and  static  electricit}'.  De  Watteville 
reports  some  curative  effects  of  galvanization  of  the  nasal  mucous 
membrane  in  chronic  cases  of  persistent  sneezing. 

ELECTRICITY   IN    DISORDERS   AFFECTING   SENSORY   NERVE-TRACTS. 

The  discovery  that  different  bundles  of  fibres  which  help  to  compose 
the  substance  of  the  spinal  cord  serve  to  convey  sensory  impulses  only, 
and  the  later  researches  which  have  also  been  made  respecting  the  paths 
of  conduction  specially  prepared  for  sensations  of  pain,  touch,  tempera- 
ture, pressure,  the  muscular  sense,  visceral  sensations,  etc.,  have  a 
practical  bearing  upon  both  diagnosis  and  treatment. 

Clinical  observations  go  to  show  that,  of  the  sepai'ate  and  distinct 
types  of  sensation  enumerated,  some  may  be  partially  or  completely 
destro^'ed  b}-  diseased  conditions  without  impairing  the  others.  Thus, 
for  example,  a  patient  under  certain  conditions-  may  be  able  to  exercise 
his  sense  of  touch  with  normal  acuteness  and  yet  be  rendered  absolutely 
insensible  to  pain;  again,  he  may  be  unable  to  discriminate  between 
degrees  of  heat  or  cold  (provided  the  tests  do  not  produce  pain), 
although  he  retains  luiimpaii'ed  sensory  faculties  in  all  other  respects. 
We  are  therefore  forced  to  recognize  a  variety  of  t^pes  of  anaesthesia 
as  presenting  themselves  for  diagnosis  and  treatmeat. 


( 


ELECTRICITY   IN    DISORDERS   OF   SENSORY  NERVE-TRACTS.     l2o 

The  sensoiy  functions  nifiv  be  either  increased  (hy2:)eraesthesia)  or 
diminished  (anffsiJiesia). 

Eitlier  of  these  states  ma}'  he  of  organic  origin  (b^'  which  we  mean 
that  structural  clinni2;es  in  tlie  nervous  tissues  accompany-  them),  or  of 
purely  functional  or /gin,  in  which  case  no  structural  changes  can  be 
sl\()wn  to  exist.  Examples  of  the  former  are  found  in  connection  witli 
central  lesions  (those  of  the  brain  or  spinal  cord),  and  with  peripheral 
lesions  of  the  sensory  nerves  or  the  organs  of  special  sense,  while  exam- 
])les  of  the  latter  are  frequenth'  encountered  in  connection  with  hyster- 
ical conditions,  neurasthenia,  cold,  injury,  imperfect  capilhay  circulation, 
rheumatism,  neuralgia,  and  man3'  other  morbid  conditions. 

In  all  forms  of  sensory  disturbance  the  removal  of  the  cause  consti- 
tutes in  many  cases  the  basis  of  a  cure,  and  the  treatment  will  necessarily 
be  modilied  by  the  causal  indications. 

Many  suggestions  which  have  previously  been  offered  respecting 
electrical  applications  to  the  brain,  spinal  cord,  and  peripheral  nerves 
are  applicable  alike  to  sensory  as  well  as  motor  disorders  when  due 
to  organic  changes;  hence,  when  this  foct  is  borne  in  mind,  it  will  be 
unnecessary  to  repeat  what  has  already  been  given. 

Anaesthesia. — In  the  treatment  of  this  morbid  condition  nothing 
can  surpass  in  its  results  the  dail}'  use  of  the  wire  brush  for  about  ten 
minutes  over  the  regions  ati'ected.  This  form  of  electrode  should  be 
applied  dr}'  and  with  the  secondary  coil  of  a  faradaic  machine.  The 
stabile  electrode  should  be  well  moistened  and  pressed  closely  in  contact 
with  some  distant  point. 

If  trophic  disturbances  coexist  Avith  anaesthesia,  I  have  found  the 
"  combined  current "  (galvano-faradaic)  to  be  more  efficacious  than 
faradaism  alone. 

Static  sparks  and  static  insulation  often  act  wonderfully  in  func- 
tional nervous  diseases. 

Static  insulation  has  been  previously  described.  It  should  be 
administered  daily  for  from  ten  to  thirtj'  minutes. 

If  the  ''indirect  sparJc'"  is  employed  (see  Fig.  176),  the  length  of  the 
spark  should  be  sufficient  to  be  perceptible  to  the  patient,  and  the  dura- 
tion of  the  application  should  seldom  exceed  five  minutes.  It  is  well  to 
administer  a  fusillade  of  sparks  to  the  region  of  the  spine  after  each 
insulation,  in  case  the  sensory  disturbances  are  dependent  upon  hysteria 
or  neurasthenia. 

I  seldom  employ  the  ''direct  spark'''  (Fig.  177)  except  in  the  treat- 
ment of  organic  disturbances  of  sensation  or  motion.  This  form  of 
administration  should  be  used  with  extreme  caution  if  the  generating 
machine  is  a  power  fid  one. 

The    "umbrella"    electrode    furnishes    an    agreeable    and    effective 


726  LECTURES   ON   NERVOUS   DISEASES. 

method  of  concentrating  static  electrlcit}-  to  tlie  head  of  the  patient. 
The  sensation  is  one  which  resembles  that  of  a  strong  l)reeze  circiihiting 
tlirouoli  the  hair. 

Hemianesthesia  (whether  of  cerebral  or  spinal  origin)  is  often 
benefited  by  cutaneous  faradization  of  limited  portions  of  the  area 
artected, — a  point  first  observed  by  Yulpian,  who  emplo3^ed  this  method 
with  marked  success. 

Trophic  disorders  may  occasionally  manifest  themselves,  often  in 
the  skin,  nails,  hair,  and  muscles,  when  sensation  is  markedl}'  affected. 
One  such  case  (suffering  from  locomotor  ataxia)  was  latch*  placed  under 
my  care.  The  fingers  of  both  sides  were  almost  destitute  of  sensibility 
to  pain,  and  tactile  sensation  was  impaired.  The  nails  were  thickened, 
loosened  for  half  of  their  length,  and  deeply  pigmented  (as  if  stained 
with  iodine).  The  terminal  phalanges  were  "  clubbed,"  the  nails  being 
bent  almost  in  a  semicircle.  The  skin  was  thickened  and  very  hard 
under  the  loosened  nails.  The  "  combined  current  "  (galvano-faradaic) 
Avith  a  wire-brush  electrode  caused  decided  improvement  within  a  few 
weeks. 

Neuralgia  (when  of  idiopathic  origin)  is  more  successfully  treated 
to-da}'  b}'  electricity  than  by  any  medicinal  agent.  In  many  instances  it 
is  cured  in  a  few  sittings. 

It  is  w^ell  to  bear  in  mind,  however,  the  fact  that  neuralgic  pains  are 
very  often  symptomatic  of  causes  more  or  less  remote  from  the  aflected 
nerve,  and  that  a  permanent  cure  is  impossible  in  many  instances  as  long 
as  that  cause  actively  exists.  Defective  teeth,  morbid  processes  in  the 
bones,  pressure  upon  a  nerve,  organic  changes  in  the  nerve  itself,  toxic 
diatheses,  rheumatism,  gout,  reflex  irritation  from  the  eye,  uterus,  digest- 
ive tract,  ovaries,  etc.,  cardiac  and  pulmonary  disorders,  and  many  other 
morbid  conditions,  may  be  enumerated  as  among  the  exciting  causes  of 
neuralgia. 

Respecting  the  electrical  treatment  of  neuralgic  pains  {jyer  se)  the 
following  deductions  ma^-  prove  of  some  advantage  to  you  : — 

1.  If  points  of  tenderness  to  pressure  (jmncta  dolorosa)  exist  along 
the  course  of  the  aflected  nerve  or  its  branches,  it  is  well  to  subject  them 
to  stabile  galvanic  applications  of  the  anode,  the  cathode  being  placed  at 
a  neutral  point. 

2.  The  anode  should  be  made  to  cover  as  large  an  area  as  possible. 

3.  The  duration  of  the  sitting  should  not  exceed  five  minutes,  save 
in  exceptional  cases.  The  sittings  may  be  repeated  several  times  a  day 
if  necessary. 

4.  As  a  rule,  it  is  unwise  to  break  the  curient.  In  obstinate  cases 
the  current  may  occasionally-  be  reversed,  without  changing  the  poles,  by 
means  of  the  commutator. 


ELECTEICITY   IN    DISORDERS   OF   SENSORY   NERVE-TRACTS.     727 

5.  Fanulization  of  the  nerve  and  the  use  of  tlie  wire  brush  upon  the 
skin  have  been  recommended  when  galvanism  proves  unsuccessful  in 
arresting  the  pain.  It  should  not  be  used  (in  my  opinion)  until  galvan- 
ism has  been  thoroughly  applied. 

0.  It  is  well  in  obstinate  cases  to  direct  the  applications  of  galvanism 
to  the  central  origin  of  the  affected  nerve,  as  well  as  to  its  peripheral 
distribution. 

7.  Static  electricity'  often  produces  marvelous  results  in  neuralgia. 
I  have  more  faith  in  it  as  a  cure  for  sciatica  than  in  any  other  remedial 
agent.  It  should  be  applied  (by  the  "  spark  "  method)  over  the  affected 
nerve.  One  sitting  has,  in  my  experience,  frequently  arrested  severe 
pain.  It  gives  immediate  relief,  in  most  cases,  to  muscular  rheumatism 
also,  and  to  lum])ago.  Sufferers  from  muscular  and  neuralgic  pains  are 
perhaps  as  frequently  encountered  by  the  physician  as  any  class,  and 
static  electricity  should  highly  recommend  itself  to  his  confidence  for 
such  cases.  The  expenses  of  the  outfit,  and  the  fact  that  the  machine  is 
too  large  for  transportation,  will  prol)al)ly  prevent  its  general  use  by  the 
profession ;  but,  until  its  effects  upon  a  patient  have  been  tried,  I  would 
caution  against  expressing  an  unfavorable  opinion,  even  if  galvanism, 
faradaism,  and  medicinal  treatment  have  proved  powerless  to  relieve  the 
suffering. 

8.  The  operation  of  electro-puncture  of  a  nerve  for  the  relief  of  neu- 
ralgia has  proved  of  benefit  in  the  hands  of  some  neurologists ;  but  it  is 
an  operation  which,  if  injudiciously  employed,  will  produce  electrolysis, 
and  serious  results  may  follow  its  use. 

9.  The  electrical  treatment  of  various  other  forms  of  pain  is  similar  to 
that  of  neuralgia.  The  judgment  of  the  physician  should  be  exercised 
regarding  the  position  and  size  of  the  electrodes,  the  variet}',  strength, 
and  duration  of  the  current  employed,  and  various  other  minor  points 
suggested  by  the  condition  of  the  subject. 

10.  Viticeral  veuraJgias  (as,  for  example,  the  conditions  known  as 
hemicrania,  migraine,  gastralgia,  enteralgia,  hepatalgia,  etc.)  are  often 
relieved  by  electricity,  irresi)ective  of  the  reflex  or  constitutional  con- 
dition which  induces  the  morbid  state.  The  removal  of  the  exciting 
cause,  however,  will  greatly  assist  in  making  the  cure  a  radical  one.  I 
have  long  taught  in  my  lectures  that  I  had  yet  to  encounter  a  patient 
who  had  suifered  for  years  from  migraine  who  had  not  some  defect  in 
the  eye  or  its  muscles  as  an  exciting  cause.  Experience  leads  me  still 
to  strongly  assert  this  as  my  conviction.  The  same  cause  is  very 
frequently  manifested  by  paroxysms  of  spinal  pain, — peculiarl}^  so  at  two 
points,  viz.,  between  the  scapuUe,  and  at  the  junction  of  the  last  lumbar 
vertebrae  with  the  sacrum. 

The  currents  which  act  best  upon  these  cases  are  the  galvanic  and 


728  LECTURES   ON   NERVOUS   DISEASES. 

static.  I  liave  in  two  instances  emploNcd  faradaism  in  cfastralfria  with 
good  results,  but  I  regard  it  as  inferior  to  galvanism  or  I'ranklinisni. 

In  treating  the  abdominal  viscera  by  galvanic  currents,  one  rlieo- 
phore  may  often  be  attached  with  advantage  to  a  ret^tal  electrode,  and 
the  other  to  a  large  electrode  placed  over  tiie  organ  to  be  influenced.  I 
do  not  believe  that  polar  eflTects  are  to  be  particularly  aimed  at.  In  some 
cases,  an  occasional  substitution  of  the  "  combined  current "  (galvano- 
faradaic)  for  galvanism  makes  the  improvement  of  the  patient  more  rapid. 

Static  applications  to  the  abdomen  are  best  made  by  employing 
indirect  sparks  of  about  two  inches  in  length.  Long  sparks  are  not 
borne  well  by  sensitive  subjects.  If  patients  are  subjected  to  static 
insulation  only  for  twenty  minutes  daily,  or  to  the  electric  spray  over 
the  abdomen,  relief  is  often  afforded  and  the  application  is  painless. 
The  clothing  need  not  be  removed  in  making  applications  of  franklinism 
by  either  of  these  methods, — a  point  which  renders  the  treatment  par- 
ticularly agreeable  to  ladies. 

ELECTRICITY   IN   DISEASES   OF   THE   CERVICAL   SYMPATHETIC,    THE 
VASO-MOTOR   SYSTEM,    AND   ALLIED   NEUROSES. 

Tlie  CERVICAL  SYMPATHETIC  is  Undoubtedly,  in  rare  cases,  the  seat 
of  isolated  morbid  changes  ;  but,  as  Erb  remarks,  these  cases  "  consti- 
tute pathological  curiosities."  The  morbid  conditions  which  have  been 
detected  embrace  inflammation,  compression,  traumatism,  rheumatic 
conditions,  etc.  Such  conditions  may  create  either  irritation  of  the 
sympathetic  system  or  paralj'sis  of  its  functions,  or  both  simultaneously 
in  ditterent  parts  of  the  body. 

Irritation  of  the  cervical  sympathetic  produces  pallor  of  the  face 
and  neck  ui)Ou  the  aflected  side,  with  a  sense  of  coldness  in  the  parts. 
The  pupils  are  dilated,  the  temporal  arteries  exhibit  increased  tension, 
the  power  of  accommodation  and  the  reaction  of  the  pupil  to  light  are 
both  impaired,  the  eyelxills  protrude  slightly,  and  the  secretion  of  sweat 
is  diminished. 

Farali/His  of  the  cervical  sympathetic  induces  the  opposite  con- 
ditions. The  skin  is  red  and  hot.  the  patent  sutlers  from  a  sense  of  heat 
in  the  sk'.n,  the  pupils  are  contracted  and  exhibit  normal  reactions  to 
light  and  accommodation  of  vision ;  the  eyeball  does  not  protrude, 
there  are  often  headache  and  vertigo,  the  secretion  of  tears  and  sweat 
is  increased,  and  the  i)ulsation  of  the  carotids,  is  excessive. 

In  the  electrical  treatment  of  these  opposed  conditions  Erb  recom- 
mends stabile  applications  of  the  anode  (with  a  strong  current)  until  a 
change  in  the  pupil  is  observed,  if  the  comlition  of  irritation  exists.  The 
same  author  suggests  tiie  use  of  the  cathode  with  a  feeble  current, 
frequent  Interruptions,  and  occasional  reversal  of  the  poles,  if  the  par 


ELECTRICITY  IX  DISEASES  OF  CERVICAL  SYMPATHETIC,  ETC.      729 

alytic  state  is  present.  He  places  the  "indifferent"  electrode  upon 
tlie  spine.  He  also  siijriiests  applications  of  the  wire  hrush,  or  labile 
galvanic  currents,  to  tiie  skin  of  the  face  and  n(!ck. 

To  the  views  of  this  author  I  would  urge  the  advantage  of  tr3'ing 
the  effects  of  static  insulation  and  sparks  directed  to  the  neck  and  face. 

Angioneuroses  of  the  skin  may  assume  one  of  two  forms,  viz., 
spasm  or  parali/sis.  Thev  are  most  frequenth^  observed  in  connection 
with  neurasthenia  and  in  hysterical  patients.  The  abnormal  contraction 
or  relaxation  of  the  vessels  may  cause  (1)  modifications  in  the  color  and 
the  general  "  feel  "  and  sensibility  of  the  skin  ;  (2)  subjective  sensations 
of  heat,  tingling,  formication,  etc. ;    (3)   disturbances   of  perspiration; 

(4)  awkwardness  of  movement  of  the  part  (especiall}^  in  the  hands);  and 

(5)  man}'  reflex  symptoms  referable  to  the  viscera. 

Unnatural  conditions  of  the  vessels  of  the  skin  (spasm  or  paralysis) 
are  most  frequently  observed  in  the  upper  limb,  less  frequent!}'  in  the 
lower  limb,  and  least  often  in  the  face  and  neck.  They  may  be  excited 
by  a  variety  of  causes, — such  as  fatigue,  excitement,  menstrual  disturb- 
ances, malaria,  exposure  to  cold,  the  etfects  of  poisons,  and  direct 
irritation  of  the  skin  itself. 

I  have  seen  the  skin  (especially  of  the  fingers)  made  as  white  as 
chalk  in  some  cases,  and  in  others  rendered  cj'anotic,  by  spasm  of  the 
vessels.  The  muscles  of  the  papillae  of  the  skin  may  particij^ate  in  the 
spasm  and  produce  the  so-called  "  goose-flesh "  appearance.  Pain, 
tingling,  formication,  partial  anaesthesia,  and  other  disturliances  of  the 
sensory  apparatus  may  occur  as  sequelae  to  the  vascular  spasm. 

Parah/sis  of  the  cutaneous  vessels  leads  to  directlj'^  opposite  con- 
ditions. The  skin  may  be  made  intermittently  or  permanentl}'  red,  and 
feel  inniaturally  hot  and  extremely  sensitive.  Subjects  so  afflicted  fre- 
(piently  suffer  from  insomnia,  headache,  disturbed  heart-action,  excessive 
])ers[)iration,  vertigo,  and  other  visceral  manifestations  of  irritabilit}'. 

Respecting  the  electrical  treatment  of  angiospasm  and  angioparal}'- 
sis,  the  general  rule  may  be  given  that  weak  or  moderate  applications  of 
faradaism  or  galvanism  to  the  affected  part  act  best  upon  dilated  vessels, 
and  stronger  currents  upon  those  affected  with  si)asm. 

Appli(;ations  of  static  electricity  are  often  very  beneficial  to  neuras- 
tl'.en'c  and  hysterical  subjects.  Personally,  I  believe  this  method  of 
treatment  surpasses  any  other  in  its  effects  upon  this  class,  although  it 
^!s  well  to  alternate  with  galvanism  and  faradaism  when  a  case  proves 
obstniate  to  treatment. 

When  any  of  the  methods  suggested  are  employed,  it  is  well  to 
subject  both  the  vaso-motor  centimes  and  the  nerve-trunks  which  supply 
the  affected  regions  (as  well  as  the  parts  directly)  to  the  influence  of 
electrical  currents. 


PLATE  I. 


A  Diagram  of  the  Motor  Points  ok  the  Face,  showing  the  Position  ok 

THE  El-ECTRODES  DURING  ELECTRIZATION  OK  SPECIAL  MUSCLES  AND  NEUVES. 

The  Anode  is  supposed  to  be  placed  in  the  Mastoid  Fossa,  and  the 
Cathode  upon  the  Part  indicated  in  the  Diagram. 
1,  m.  orbicularis  palpebrarum ;  2,  m.  pyramidalis  nasi ;  3,  m.  lev.  lab.  sup.  et  nasi ;  4,  m. 
lev.  lab.  sup.  propr. ;  5.  6,  m.  dilator  naris;  7,  m.  zysoniatie  major;  8,  m.  orbicularis 
oris  ;  9,  n.  branch  for  levator  menti ;  10,  m.  levator  nienti;  11,  m.  quadratus  nienti; 
12,  m.  triang:ularis  menti ;  1;?,  nerves,  subcutaneous,  of  neck  ;  14,  m.  sterno-hyoid  ;  lo, 
m.  omo-hyoid  ;  l(i,  m.  sterno-thyroid  ;  17,  n.  brancb  for  platysma  :  IS,  m  sterno-hyoid  ; 
19,  ni.  omb-hyoid ;  20,21,  nerves  to  pectoral  muscles;  22.  m.  occiiiitofroiitalis  (ant. 
belly) ;  23,  m.  occipito-frontalis  (post,  belly)  ;  24,  m.  retrahens  and  attollcns  ;uirem  ; 
25,  nerve— facial :  2<j,  m.  .stylo-hyoid ;  27,  m.  digastric;  2S,  m.  splenius  capitis;  29, 
nerve— external  branch  of"  spinal  accessory;  30.  m.  sterno-mastoid  ;  31,  m.  sterno- 
niastoid ;  32,  m.  levator  anguli  scapuliB ;  33,  nerve— phrenic  ;  34.  nerve— posterior 
thoracic  ;  3o,  m.  serratus  magnus ;  36,  nerves  of  the  axillary  space.  In  this  text 
m.  =  muscle  ;  n.  •—  nerve. 


(731) 


PLATE  TT. 


M  external  head  of  tricepi. 


MuBcnlo-spirnl  nervo       •  "■■  w> 
M.  brachiaiia  anticub  •    ^ 

M.  Bupiuator  lon^ia 
M.  extensor  carpi  rad.  longioi 

M.  extensor  carpi  rad.  brevioi 


Thk  Motce  Points  on  the  Outeb  Abpkot  of  ijra  Aem. 


(732) 


PLATE  III. 


TiiK  Motor  Points  ox  thk  In.vek  Sidk  of  the  Aum. 
1,  in.  internal  head  of  tricei>s ;   2,  niusculo-outaneous  nerve;  •?,  median  nerve:  i.  in. 
loraeo-hraeliialis:  5,  ulnar  nerve:  (>.  branch  of  median  nerve  for  proiKitor  radii 
teres  :  7.  nHif<eul<)-cntaneous  nerve  ;  S,  m.  biceps  flexor  eubiti. 


(733) 


PLATE  IV. 


The  Motor  Points  on  the  Extensok  (Posterior)  Aspect  of  the  Forearm. 

1,  111.  supinator  loiifjus ;  2.  m.  extensor  carpi  rart.  longior :  :S,  m.  extensor  carpi  rad. 
brevior ;  4.  o.  in.  extensor  cominunis  tligitorum  :  b.  in.  extensor  ossis.  met.  pol. :  7, 
m.  extensor  primi.  internod.  pol. :  8.  in.  first  dor.sal  interosseous :  9,  lu.  second  dor- 
sal interosseous;  10,  m.  third  dorsal  interosseous;  11.  in.  extensor  carpi  ulnaris; 
12.  m.  extensor  min.  diffiti ;  IS,  m.  extensor  seciiiid.  internod.  pol. ;  14,  m  abduct, 
lain,  digiti ;  15,  ui.  fourth  dorsal  intero.sscous. 


(734) 


PLATE  V. 


The  Motor  Points  on  the  Flexor  (Antertoe)  Aspect  of  the  Forearm. 
1,  median  nerve  and  branch  to  ni.  pronator  radii  teres ;  2.  m.  pahnaris  longiis ;  8.  m. 

flexor  carpi  ulnaris ;  4,  ni.  flexor  snl)liui.  dij^it.  ;  5,  ulnar  nerve;  0,  m.  flex,  sublim. 

dig. ;  7,  volar  branch  of  the  ulnar  nerve  ;  8,  ni.  jialniaris  brevin  :  0.  m.  abductor  niin. 

digit. ;  10,  m.  flexor  min.  digit. ;  11,  m.  opponciis  uiiu.  digit.  ;  V2.  i:!,  ni.  liunbricales  ; 

14,  m.  flexor  carpi  radialis  ;  1.5,  ni.  flexor  i)riit  luid.  digitorura ;  Ki,  in.  flexor  sublim. 

digitorura  ;  17,  m.  flex,  longus  poIlici.s  ;  18,  median  nerve  ;  lit,  m.  opponeus  pollici8_; 

20,  m.  abductor  iHillicis ;  21,  m.  flexor  brevis  pollicis;  "22,  m.  adductor  poUicis ;  23, 

m.  flrst  lurabricali«. 


(735) 


PLATE  VI. 


12 


The  Motor  Points  on  the  Posterior  Aspect  ok  the  Thioh. 
1,  branch  of  tlie  inferior  gluteal  nerve  to  the  gluteus  niaximus  muscle;  2,  sciatic 
nerve  ;  0.  long  head  of  hiccits  muscle  ;  4.  short  head  of  biceps  muscle ;  i>,  adductor 
magniis muscle  ;  6,  senii-tendiuosus  muscle  ;  7,  semi-membranosus  muscle  ;  S,  tibial 
nerve;  9,  peroneal  nerve;  10,  external  head  of  gastrocnemius  muscle;  11,  sulcus 
muscle  ;  12,  internal  head  of  gastrocnemius  muscle. 


PLATE  VII. 


1  — 


4    . 


TiiK  MoToK  Points  on  the  Antkrior  Aspect  of  tiik  Thigh. 
1,  cniral  nerve  ;  2,  obturator  nerve  ;  3,  sartorius  muscle ;  4,  adductor  lonj^us  nniscle ; 
').  branch  of  the  anterior  crural  nerve  for  the  quadriceps  extensor  muscle  ;  <i,  the 
•luadriceps  muscle;  7,  branch  of  anterior  crural  nerve  to  the  vastus  internus 
muscle  ;  S,  tensor  vaginae  femoris  muscle  (supplied  by  the  superior  gluteal  nerve) ; 
'.•.  external  cutaneous  branch  of  anterior  crural  nerve ;  10,  rectus  femoris  muscle ; 
II,  12,  vastus  externus  muscle. 


47 


^737) 


PLATE  VIII. 


1  — 


4 


The  Motok  Points  on  the  Inner  Aspect  of  the  Leg. 

1,  internal  head  of  gastrocnemins  muscle :  2,  soleus  muscle  ;  3,  flexor  pomnmnis  digi- 

tonnu  muscle ;  4,  posterior  tibial  nerve  ;  5,  abductor  iwUicis;  iiiu.-<cle. 


(788) 


PLATE  IX. 


TiiK  Motor  Points  on  the  Uutek  Aspect  ok  the  Leg. 
1,  peroneal  nerve  ;  2,  external  head  of  gastrocnemius  muscle;  3,  soleus  muscle  ;  4.  ex- 
tensor communis  digitorum  muscle  ;  5,  peroneus  brevis  muscle  ;  0,  soleus  muscle ; 
7,  tk'xor  long'is  pollicis  ;  8,  peroneus  longus  muscle  ;  It,  tibialis  anticus  mus(;le  ;  10, 
extensor  longus  pollicis  muscle:  11,  extensor  brevis  digitorum  muscle:  12.  ab- 
ductor minimi  digiti  muscle  ;  l.>,  deep  branch  of  the  i)eroncal  nerve  to  the  extensor 
brevis  digitorum  muscle ;  14,  14,  14,  dorsal  interossei  muscles. 


(739) 


PI-ATE  X. 


Tirr.  Xkkvovs  Distriiution  of  the  Ski.v  of  tiik  Head.  (After  Flower.  Init 
slij^htly  nioi'.itied.) 

1,  region  .'^npplied  hy  the  supra-orbital  branoli  of  the  fifth  nerve:  2.  region  sxiiniliod 
l)y  the  supra-tr6chlr(tr  branch  of  the  fifth  nerve  :  '■'.  region  supplied  by  the  inj'rn- 
trurhlrar  branch  of  the  fifth  nerve  :  4.  region  supplied  by  the  in/ra-orbilai  branch 
of  the  fifth  nerve  ;  •"),  region  sui)plied  bv  the  buccal  branch  of  the  fifth  nerve  :  r., 
region  supjilied  by  the  mental  branch  of  the  fifth  nerve  ;  7,  region  sui)i)lied  by  the 
xujurficial  cervical  from  the  cervical  plexus;  S.  region  supplied  by  the  iircal 
auricular  from  the  cervical  plewis;  9,  region  .supplied  by  the  lcti>j)tiro-iu<iliir 
branch  of  the  fifth  nerve:  lo,  region  supplied  by  the  ladiri/tiial  bianch  of  the 
fifth  nerve:  H.  region  sui)plieil  by  the  anriculo-tcniporal  liranch  of  the  filtb 
nerve:  12,  region  supplied  by  the  great  occipital  (a  spinal  nerve)  ■  l-'i.  region  su))- 
plied  by  the  small  occipital  from  the  cervical  plexus  ;  11,  regiou  supplied  by  the 
supra-clavicular  from  the  cervical  plexus. 


The  Cutaneous  Nerve  Supply  of  the  Posterior  Portion  of  TIead  and 
Neck.    (Modified  from  Flower.) 

1,  region  supplied  by  the  great  occipital  nerve  ;  2,  region  supplied  by  the  auriculo- 
temporal nerve  ;  o.  region  supplied  by  the  small  occipital  nerve  :  4.  region  supplied 
by  the  great  auricular  nerve ;  5,  region  supplied  by  the  third  cervical  nerve. 


(740) 


PLATE  XI. 


!«.«»^' 


II 


A  Dfaokam  of  the  Regions  of  Cutaneous  Nerve  Distrirution  in  thk 
Anterior  Surface  op  the  Upper  Extremity  and  Trunk.  (Modified 
from  Flower.) 

1,  rcffioii  suiJiilied  by  the  sujjra-clavicular  nerve  (branch  of  the  oervioal  iilexus) ;  2, 
region  supplied  l)y  the  circumflex  nerve;  3,  region  supplied  by  the  intercosto- 
luimeral  nerve  ;  1.  region  supplied  by  the  intercostal  nerve  (lateral  branch) ;  5, 
regiou  supplied  V)y  the  lesser  internal  cutaneous  nerve  (nerve  of  Wrisbergi  ;  fi. 
region  supplied  by'the  niusculo-spiral  nerve  (external  cutaneous  branch)  ;7.  region 
supi)lied  by  the  internal  cutaneous  nerve;  8.  region  supjtlicd  by  the  nmsi'ulo- 
cutant'Dus  nerve  :  !),  region  supplied  by  the  median  nerve  :  10.  region  supplie<l  by 
the  ulnar  nci-vo  :  II.  region  supplied  by  the  intercostal  nerve  (anterior  liraneh). 


(741) 


PLATE  Xll. 


A  I)iA(;nAM  OF  THE  1\i:<;ions  ok  Cutankous  Nkijvk  DisTiriuiTioN   on  the 

PoSTKinOK  SUHKACK  OF  THK    UPI'KK    EXTKKMITY    AM»    TiMNK.       (Moilitiftd 

from  F'lower.) 
1>^.  region  supjilietl  by  the  second  dorsal  nerve  ;  19,  region  supplied  hy  the  xiipra- 
scajmlnr  nerve  :  20,  region  supplied  by  the  cireumflcv  nerve  :  21,  region  supplied 
by  the  intercos/o-hunwral  nerve;  22,  "region  sui>i>iied  by  the  txtcnud  ndiiiicons 
nerve  ;  2.S,  region  sui>i)lied  by  the  intcrndl  ciilainou.s  brunch  of  the  /niixcidn-xpiral 
nerve  ;  24,  region  hnpi>lied  by  the  "  nrrrr  of  Wrishrrfi  : ''  2.j,  region  supi>Iied  liy  the 
lateral  braiiclic.s  of  the  iniercos/al  nerves;  2(),  region  su})plied  !iy  the  iidirnal 
cidaiif'iiiis  nev\i\  ;  27,  region  supjilied  by  tlie  iniaicido-ctUftneoiix  nerve:  2S.  region 
sup)ilied  liy  tin-  iliar  brunch  of  tlie  ilin-iin/ninal  nerve  ;  21t.  region  siii>plied  by  the 
ratliol  nerve  ;  ."{0,  region  supplied  by  the  idnur  nerve. 


(742) 


PLATE  Xlli. 


\    \\ 


6    I 


A  l)iAGi;.\.M  oi'"  THE  Cutaneous  Sutim-y  of  thk  An  tkkioi;  aspkc't  ok  the 
I^OWER  Extremity.     (Modified  froui  Flmver.) 

1,  roiriou  supiiliod  liy  tlie  lateral  branches  of  tlie  intercostal  nerves  :  2.  rejrion  supi>lied 
liy  the  anterior  branches  of  the  intercostal  nerves:  fi.  region  supplied  by  the  ilio- 
hyiioo-astric  nerve  ;  4,  region  supplied  by  the  ilio-injiuinal  nerve  ;  ■">.  rcjrion  sui)i)lied 
by  the  genito-crural  nerve  ;  6,  re.<ri(in  su]))ilied  by  the  middle  cutaneous  branch  of 
the  anterior  crural  nerve  ;  7.  region  sui>])li('d  bv  the  internal  cutaiionus  branch  of 
the  anterior  crural  nerve  and  jiartly  by  tlie  obturator  nerve :  K.  region  supplied  by 
the  external  cutaneous  nerve  ;  !i.  region  sujiplied  by  the  long  saiihcnous  branch  of 
the  anterior  crural  nerve  ;  lit.  region  sni)i)!ied  by  the  brambcs  of  the  external 
popliteal  nerve  :  1 1,  region  supplied  l>y  the  inusculo-cntancfuis  nerve  :  \'l.  region  sup- 
])lied  by  tlie  terininal  filanicnts  of  the  niuscnlo-cutancous  ner\  e  :  IM.  region  supplied 
by  the  external  saphenous  nerve;  14,  region  supplied  by  the  anterior  tibial  nerve. 


(,743) 


PLATE  XIV. 


A  Dtagkam  of  Tin-;  ("rrAXEous  Si'pply  of  the  Postekiou  Asvkct  of  tiik 
T-o\VKi;  Extremities.    (Modified  from  Flown  ) 

1"),  ri'^jion  sni>i)li('d  by  tlie  lateral  branches  of  the  intercostal  ncrM-s  :  Iti.  resion  sup- 
plietl  liv  the  |iiisterior  branches  of  the  Innibar  nerves:  17.  reprion  sniiplied  by  the 
iliac  branch  of  the  ilio-hypop;astric  nerve  :  18.  region  supiilied  b\  the  juidic  nerve  ; 
lit,  reprion  sniiplicd  by  the  inferior  glnteal  branch  of  the  small  sciatic  nerve  :  'Jo, 
rejjion  snpplicil  by  the  external  entaneous  nerve:  21.  rctrion  sti|iplicd  by  the 
internal  cutaneous  biancli  ol  the  anterior  crural  nerve  :  'ii.  rejiion  supplied  by  the 
small  and  great  sciatii-  nerves  :  2;i.  region  supplied  by  branches  from  the  external 
pu|)liteal  nerve:  'Jt.  region  supi>lieil  by  the  external  saphenous  nerve:  i>,  region 
supplied  li\  tlij  jiosterior  tibial  nerve.  " 

(744) 


GLOSSARY. 


Accommodation  op  Vision.     The  adjustment  of  the  crystalline  lens  of  the  eye  for  the 

clear  perception  of  objects  within  a  radius  of  twenty  feet  from  the  eye.     It 

is  usually  estimated,    however,  at   about    fourteen    inches   from    the    eye 

(Fig.  39). 
yEsTHESiOMETER.     An  instrument  to  estimate  the  acuteness  of  the  tactile  sense  in  any 

given  part. 
.(EsTHESODic.     Pertaining  to  the  appreciation  and  conduction   of  sensations  of  various 

kinds.     Centripetal. 
Ageusia.     A  loss  of  taste. 

Agraphia.     A  loss  of  the  ability  to  write  or  copy  familiar  characters  correctly. 
Akinesia.     A  loss  of  voluntary  motion. 
Alexia.     A  loss  of  the  power  of  reading. 
Amblyopia.     Indistinct  vision  from  structural  changes  accompanying  disease  of  the  eye 

or  optic  nerve. 
Amimia.     a  loss  of  the  power  of  making  appropriate  gestures. 
Amnesia.     A  loss  of  memory. 
Amygdala.     It  literally  signifies  the  "  almond."     The  term  is  applied  to  a  mass  of  gray 

matter  seen  after  a  section  made  through  the  tail  of  the  caudate  nucleus  of 

the  cerebrum  (N  C''  m  Fig.  9). 
Amyotrophic.     A  term  which  signifies  defective  nutrition  of  muscles. 
Analgesia.     The  abolition  of  sensibility  to  pain  in  any  part. 

Anarthria.     a  peculiar  form  of  imperfect  speech  due  to  interference  with  the  speech- 
tract  (Fig.  24). 
Anode.     The  positive  pole  of  a  galvanic  battery. 
Anosmia.     The  abolition  of  the  sense  of  smell  in  one  or  both  nostrils. 
Aphasia.     A  morbid  condition  where  speech,  reading,  or  writing  become  impaired,  either 

from  an  inability  to  properly  coordinate  the  muscles,  or  from  a  defective 

interpretation  of  sounds  or  visual  impressions. 
Apraxia.     a  loss  of  the  power  to  recognize  common  objects  and  often  to  apfireciate  their 

ordinary  uses. 
AsEMiA.     See  Ani/mhoUa. 
Associating  Tracts.     Fibres  which  serve  to  unite  the  various  physiological  centres  of 

each  side  of  the  brain,  and  also  of  the  cord,  with  each  other,  so  as  to  allow 

of  a  harmony  of  action  and  the  proper  fjerformance  of  comjilicated  mental 

and  physical  processes  (Fig.  6). 
Asthenopia.     An   inability  to  use  the  eyes  without  great  discomfort.      It  is  usually 

dependent  upon  a  disturbance  of  equilibrium  in  the  eye-muscles,  with  or 

without  some  coexisting  error  of  refraction. 
Astigmatism.     An  abnormal  condition  of  vision  caused  by  irregularity  in  the  curvature 

of  the  cornea  or  crystalline  lens  of  the  eye. 
Asymbolia.     Loss  of  power  by  a  patient  of  signing  or  duplicating  his  or  her  customary 

signature. 
Ataxia.     A  morbid  condition,  characterized  by  a  loss  of  the  normal  power  of  performing 

coordinated  movements. 
Athetosis.     Constant  and  uncontrollable  movements  of  the  fingers  or  toes  (Fig.  47). 
Basal  Ganglia.     Collections  of  nerve-cells  buried  within  the  substance  of  each  cerel)ral 

hemisphere  near  to  its  base.      See  Corpus  Striatum  and   Optic    Thalamus 

(Fig-  !)■ 
Basis  Cruris.    See  Crusta  Crtiris  (Fig.  11). 

Bell's  Paralysis.     Unilateral  facial  palsy, 

Betz's  Cells.     The  motor  cells  of  the  cerebral  cortex.     They  are  arranged  in  groups  of 

five  or  six,  called  "  Betz's  ne.sts."      They  are  found  only  in  the  so-called 

"  motor  area." 
Blind  Spot.     The  point  in  (he  retina  wIhmo  the  optic  nerve  enters. — about  two  lines  to 

the  nasal  side  of  the  macula  hitea. 

(745) 


I 


746  GLOSSARY.  1 

BouLiMiA.     Insatiable  hunger. 

Brach-Bomeerg  Symptom.     An  inability  to  stand  without  swaying  or  staggering  vrhc.n 

the  eyes  are  clcscd.     It  indicates  anafsthesia  of  the  soles  of  the  feet,  and  in  i' 

frequently  observed  in  locomotor  ataxia.  ' 

BuLBAK  Symptoms.  A  train  of  sjmptoms  referable  to  the  tongue,  lips,  palate,  pharynx, 
and  larynx,  caused  by  a  degeneration  of  those  nuclei  in  the  medulla  (Fig. 
10)  which  preside  over  movements  of  the  respective  parts.  [JJuchenyie's 
disease.)  £ 

Burdach's  Column.     The  postero-external  column  of  the  spinal  cord  (Fig.  29).  |i 

Calorimeter.     An  instrument  for  the  actual  estimation  of  heat,  or  the  comparison  of  the  '■ 

relative  temperature  of  differing  |iarts. 

Capsular  Fibres.  Two  distinct  masses  of  fibres  which  embrace  and  act  as  a  capsule  to 
the  lenticLtlar  nucleus  of  the  corpus  striatum.  They  are  designated,  from 
their  relationship  to  this  body,  as  the  "  internal  capsule  "  and  "  external  cap- 
sule" (Fig.  9).  They  are  prolonged  dorsad  into  the  crus  and  pass  cephalad 
into  the  corona  radiata. 

Cardialgia.     Neuralgic  paroxysms  in  the  region  of  the  heart. 

Cat.^lepsy.  a  morbid  condition,  characterized  by  coma  and  the  so-called  "  waxy  flexi- 
bility "  of  the  muscles. 

Cathode.     The  negative  pole  of  a  galvanic  batterj'. 

Central  Convolutions.  The  ascending  frontal  and  ascending  parietal  gyri  of  the  cere- 
brum (Figs.  4  and  5). 

Centre.  A  term  commonly  employed  to  designate  some  special  subdivision  of  any  collec- 
tion of  nerve-cells  which  has  diversified  physiological  functions.  It  is  often 
used  synonymously  with  the  term  "  nucleus." 

Cheirospasm.     Writer's  cramp. 

CheyneStokes  Respiration.  An  abnormal  form  of  respiration  in  which  the  rhythm 
undergoes  frequent  and  regular  modifications. 

Choked  Disk.  The  condition  of  the  retina  observed  in  connection  with  neuro-retinitis 
(Fig.  87). 

Cincture-feeling.  A  synonym  for  the  so-called  "  girdle-pain."  A  sense  of  painful  con- 
striction of  some  part. 

Clarke's  Column.  A  column  of  cells  in  thespinal  gray  matter,  probably  associated  with 
the  transmission  of  visceral  sensations  to  the  cerebellum  by  means  of  the 
direct  cerebellar  column  (Fig.  32). 

Clavate  Nucleus.  A  collection  of  cells  which  are  structurally  related  to  the  fibres  of  the 
column  of  GoU,  and  in  which  they  probably  end.  See  also  Triangular 
Nucleus. 

Commissural  Tracts.  Fibres  which  tend  to  unite  the  cells  of  homologous  parts  of  the 
cerebral  hemispheres,  chiefly  of  the  cerebral  cortex  (F'ig.  6). 

CoNTRACTUjiE.  A  permanent  rigidity  and  shortening  of  a  muscle.  It  is  commonly  ob- 
served in  connection  with  lesions  involving  the  crossed  pyramidal  tracts 
of  the  spinal  cord.  , 

Corona  Radiata.  This  term  embraces  all  the  fibres  which  pass  from  the  cerebral  cortex 
toward  the  region  of  the  crus  (peduncular  group).  Some  are  structurally 
associated  with  the  basal  ganglia,  while  others  constitute  the  so-called  "cai- 
sular  fibres  "  of  the  lenticular  nucleus.     See  Capsular  Fibres. 

Corpus  Striatum.  This  term  literally  signifies  the  "striped  bodj-."  A  ganglion  of  the 
cerebrum,  consisting  of  two  nuclei  (the  caudate  and  the  lenticular).  It  i- 
one  of  the  so-called  "basal  ganglia"  of  the  cerebrum  (Figs  1  and  9). 

Cortex.  A  term  that  literally  signifies  "rind"  or  "external  covering."  It  is  applied, 
therefore,  to  the  gray  matter  of  the  convolutions  of  the  cerebrum  and 
cerebellum 

Crossed  Paralysis.  A  condition  where  right  or  left  hemiplegia  coexists  with  a  paralysis 
of  some  cranial  nerve  of  the  opposed  side.  It  varies  in  type,  according  t" 
the  cranial  nerve  impaired. 

Crusta  Cruris.     The  anterior  or  motor  part  of  the  crus  cerebri  (Fig.  11). 

Cuneate  Nucleus.     See  Triangular  Nucleus. 

Cuneus.  a  part  of  the  cortex  of  the  occipital  lobe  of  the  cerebrum,  lesions  of  which  tend 
to  cause  homonymous  hemianopsia. 

Delayed  Sensation.  A  peculiar  retardation  of  the  transmission  of  tactile  pain  or 
temperature  sensations  to  the  seat  of  consciousness  of  such  sensations  within 
the  cerebral  cortex. 


GLOSSARY.  747 

Diplopia.  Double  vision.  This  may  be  hahUual,  as  exists  with  strabismus ;  or  transient, 
as  observed  in  many  cases  of  heteroi.ihoria.  Tliis  distinction  is  of  great 
clinical  importance. 

Dpchenne's  Palsy.     See  Bulbar  Symptoms. 

DyNAMOMETER.  An  instrument  to  determine  the  relative  muscular  power  in  the  hand  or 
foot  of  the  two  sides. 

Dysphagia.     Difficulty  in  swallowing.     A  frequent  symptom  of  Duchenne's  disease. 

Dyspncea.     Difficult  respiration. 

Eclampsia.     Acute  attaclis  of  epileptiform  spasms. 

Electrodes.  The  terminal  attachments  to  an  electrical  instrument,  by  means  of  which 
electrical  currents  are  applied  to  a  patient. 

Embolism.  Plugging  of  a  blood-ves-sel  by  a  clot  or  foreign  body  which  has  been  trans- 
ported to  the  seat  of  its  lodgment  by  means  of  the  blood-current. 

Emmetropia.     Tiie  power  of  vision  with  an  eye  wliose  axes  are  normal  (Fig.  38). 

Encephalorrhagi.\.     Cerebral  hemor)hage.     Cerebral  apoplexy. 

Ependyma.     The  gray  lining  of  the  ventricular  cavities  of  the  brain. 

Esophoria.     a  tendency  on  the  part  of  the  visual  lines  to  deviate  inward; 

ExoPHORiA.     A  tendency  of  the  visual  lines  to  deviate  outward. 

Faradaism.  Tlie  employment  of  the  interrupted  current  generated  by  the  magnetizing 
ami  demagnetizing  of  a  soft-iron  core  within  a  helix. 

Fasciculis  Teretes.     8ee  Round  Bundle. 

Fibrillary  Twitchings.  .Slidit  muscular  contractions  of  a  fibrillary  character.  These 
may  be  observed  after  tapping  or  faradizing  the  skin,  blowing  on  the 
skin,  or  exposure  of  the  skin  after  disrobing.  They  are  most  frequently 
met  with  as  a  symptom  of  progressive  muscular  atrophy. 

Fillet.     See  Lemniscus  Tract. 

Fissure.  A  prominent  and  distinct  demarcation  between  component  parts  of  the  brain, 
the  spinal  cord,  etc.     See  Sulau.s. 

FooT-cLONi'S.  A  morbid  reflex  phenomenon  observed  at  the  ankle,  in  connection  witli 
spinal  diseases. 

Formication.  A  feeling  "as  if  ants  were  creeping  over  a  part."  One  of  the  many  sub- 
jective phenomena  caused  by  organic  and  functional  disease  of  the  nerve- 
centres. 

Franklinism.  The  employment  of  electricity  generated  from  glass  plates  by  means  of 
friction.  'Ihe  so-called  "induction  machines"  are  now  generally  employed 
for  medical  purposes. 

Friedreich's  Disease.     The  so-called  "hereditary  ataxia"  or  "  generic  ataxia." 

Galvanism.     The  employment  of  a  current  generated  by  means  of  a  chemical  action. 

Galvanometer.     An  instrument  for  measuring  the  current-strength  of  a  galvanic  battery. 

Ganglion.  Any  isolated  eollection  of  nerve-cells ;  usually  possessing  considerable  mag- 
nitude and  distinctly  marked  boundaries. 

Generic  Ataxia.     See  FriedreicJis  Disease. 

Girdle-pain.     See  Cincture-feeling.  • 

Glieder's  Members.     Subdivisions  of  the  lenticular  nucleus.     See  Figs.  6  and  9. 

Glossoplegia.     Paralysis  of  the  hypoglossal  nerve,  causing  a  loss  of  control  uf  the  tongue. 

(Joll's  Column.     The  postero-median  column  of  the  sjjinal  cord  (Fig.  21t). 

Graphospasm.     Writer's  cramp. 

Gubler's  Line.  An  imaginary  line  connecting  the  points  of  apparent  origin  of  the 
trigeminal  nerve-roots  (Fig.  26). 

Gyrus.     A  synonym  for  "convolution." 

H^matomyelia.     Spinal  apoplexy. 

HiEMATORRHACHis.     Meningeal  spinal  apoplexy. 

IIemian.i-.sthesia.     Impairment  of  tactile  sensibility  in  one  lateral  half  of  the  body. 

Hemianopsia.  Blindness  of  one  lateral  half  of  the  retina.  Three  varieties  are  to  bo 
clinically  recognized, — the  hoinoni/tnou.s,  tlie  bi-nasal.  and  the  hi-temporal. 

ITemichorea.     Convulsive  twitchings  of  the  right  or  left  half  of  the  bod}'. 

Hemiopic  Pupillary  Reflex.  A  response  of  one  lateral  half  of  the  pupil  only  to  a 
concentrated  pencil  of  light.  It  is  advisable  to  throw  tlie  beam  upon  the 
iris  at  an  obtuse  angle. 

Hemipar.\plegia.     Paralysis  of  one  lower  limb. 

Hemiplegia.     Paralysis  of  the  lateral  half  of  tlie  body, — right  or  left  arm  and  leg. 

IIeterophoria.  a  disturbance  of  the  luinual  state  of  equilibrium  in  the  muscles  which 
move  the  eyes. 


748  GLOSSARY. 

Hydbomtet.ia.     Cavities  within  the  substance  of  the  spinal  cord. 

Hydruria.     An  ahnorraal  secretion  of  sugar  by  the  kidneys. 

HypervJ'ISTUksia.     An  abnormal  acuteness  of  sensibility  in  a  part.  ^ 

Hyi'ERGEusia.     Abnormal  sensitiveness  of  the  taste-apparatus.     Often  accompanied  by  \ 

parageusia. 
Hyperkinksis.     Spasmodic  disease. 
Hypermetropia.     a  defect  in  vision   caused   by  an  abnormal   shallowness  of  the  eye 

(Fig.  38).     Its  existence  is  commonly  masked  by  abnormal  ciliary  action. 

It  is  revealed  after  the  full  effects  of  atropine. 
Htperosmia.     Abnormal  acuteness  of  smell, — often  associated  Avith  parosmia. 
Hy'perpkoria.     a  tendency  of  the  visual  lines  to  assume  different  vertical  planes. 
Hypoglossal  Tract.     A  bundle  of  fibres  which  serves  to  connect  the  cortical  centre  for 

the  tongue  with  the  hyjioglossal  nucleus  of  the  medulla  oblongata. 
Internal  Capsule.     One  of  the  paths  of  those   peduncular   fibres   that   are   probably 

unassociated  structurally  with  the  cells  of  the  basal  ganglia  of  the  cerebrum. 

See  Capsular  Fibres.     These  fibi-es  constitute  an  internal  capsule,  as  it  were, 

to  the  lenticular  nucleus  (Fig.  9). 
Intee-olivary  Tract.     A  part  of  the  lemniscus  tract,  lying  betAveen  the  olivary  bodies 

of  the  medulla  oblongata  (Fig.  27).     It  probably  constitutes  a  part  of  the 

so-called  "fillet." 
Kinesodic.     Pertaining  to  the  power  of  motility.     Centrifugal. 

Kussmaul-Lasdry's  Paralysis.     The  so-called  "acute  ascending  spinal  paralysis." 
Lemniscus  Tract.     A  term  used  synonymousl}-  with  the  so-called  "fillet."     A  bundle 

of  fibres  in  the  pons  and  medulla,  which  is  probably  associated  with  coor- 
dination of  movement,  and  possibly  also  with   our   dependence  upon  the 

visual  sense  as  an  aid  to  coordination  (Figs.  12,  36,  37). 
Macropsia.     An  apparent  magnifying  of  visual  images  by  the  eye. — due  to  paresis  of  the 

external  rectus  muscle.     Objects  appear  abnormally  large  to  the  patient. 
Macula  Lutea.     The  retinal  area  for  distinct  visual  perceptions. 
Malum  Cotunnii.     Iseui-algia  of  the  sciatic  berve.     Sciatica. 
Mastodynia.     Neuralgia  of  the  breast. 
Megalupsia.     An  apparent  exaggeration  of  the  size  of  objects  when   viewed   by  the 

eye, — due  to  paresis  of  the  external  rectus. 
Micropsia.     An  apparent  diminution  of  the  size  of  familiar  objects  when  viewed  by  the 

eye, — due  to  paresis  of  the  internal  rectus. 
Migraine.     Ilemicrania.     Sick-headache. 
MiLLiA.Mpf;RE.     The  unit  of  current-strength  employed  in  medical  treatment  of  disease 

by  galvanism. 
Milliampi:re-meter.     A   medical   galvanometer   for    estimating    the    current-strength 

during  galvanic  applications. 
Mogigraphia.    Writer's  cramp. 

MoNOAN.ESTiiESTA.     Impairment  of  tactile  sensibility  in  some  distinctly  localized  part. 
Monopar-^jstiiesIjE.     Subjective  sensory  phenomena  confined  to  some  special  part, — such 

as  tingling,  numbness,  formication,  etc. 
Monoplegia.     Paralysis  of  some  special  group  of  muscles  not,  as  a  rule,  supplied  by  one 

nerve.     It  differs  from  jiaralysisof  aspinal  nerve-trunk  in  the  latter  respect. 
Monospasm.     Uncontrollable  spasmodic  movements  of  some  special  group  of  muscles  not, 

as  a  rule,  supplied  by  one  nerve. 
Motor  Tracts.     Those  fibres  which  are  functionally  associated  with  voluntary  motion. 

They  arise  from  the  cells  of  the  "motor  area"  of  the  cortex  of  each  hemi- 
sphere of  the  cerebrum.     The  "  pyramidal  tracts  "  are  the  paths   for  these 

fibres  within  the  spinal  cord.     The  motor  fibres  traverse,  in  order  to  reach 

the  spinal  cord,  the  following  parts  successively :  The  corona  radiata,  the 

internal  capsule,  the  crusta  cruris,  the  pons,  and  the  anterior  pyramids  of 

the  medulla  oblongata  (Fig.  12). 
Muscular  Sense.    The  power  of  analyzing  any  muscular  effort  being  exerted  by  the 

patient.     Tlie  relative  position  of  the  limbs  is  also  thus  estimated,  the  aid  of 

the  visual  sense  being  excludeil. 
Mydriasis.     Preternatural  dilatation  of  the  pupil. 
My^opia.     A  defect  in  vision  due  to  an  increase  of  the  anteroposterior  axis  of  the  eye  over 

the  normal  standard  (Fig.  38). 
Myosis.     Preternatural  contraction  of  the  pupil. 
Myotonia  Congenita.     See  Thomscn's  Disca^:. 


GLOSSARY.  749 

Myxcedejia.  a  morbid  state,  characterized  by  a  swelling  and  distortion  of  the  outlines 
of  the  features,  from  a  deposit  of  mucin  beneath  the  skin. 

Necrotic  Softening.     Death  of  a  part  from  a  sudden  arrest  of  its  blood-supplj'. 

Neutral  Pole.  The  pole  whose  effects  are  not  being  observed  during  a  galvanic  applica- 
tion by  the  polar  method. 

Nuclei  of  Stilling.  The  so-called  "red  nuclei"  situated  in  the  tegmentum  cruris. 
Sue  Bed  Nuclei  {Fig.  11). 

Nucleus.  Any  collection  of  nerve-cells,  pos.«essing  some  special  physiological  function  ; 
but  often  without  distinct  limits  of  demarcation  from  neigliboring  cells. 

Nystagmus.     Oscillatory  movements  of  the  eyeballs. 

(Edema.  Transudation  of  the  sero-albuminous  elements  of  the  blood,  without  a  rupture 
of  the  vessels. 

Ophthalmoplegia.  Paralysis  of  the  muscles  whicii  move  the  ej^eball,  cnusing  straliismus 
of  varying  types. 

Optic  Thalamus.  This  term  literally  signifies  the  "  bed  "  of  the  optic  fibres.  It  is  one 
of  the  "  basal  ganglia"  of  each  hemisphere  of  the  cerebrum  (Fig.  1). 

Orthophoria.     The  normal  state  of  the  equilibrium  in  muscles  which  move  the  eyes. 

Parageusia.  Abnormal  subjective  symptoms  referable  to  taste.  This  condition  is  usually 
observed  in  hysterical  and  insane  subjects.  These  sensations  are  apt  to  he 
nauseous  and  perverse. 

Paraphasia.  The  substitution  of  wrong  words  in  conversation  ;  an  incorrect  use  of 
numerals,  etc. 

Paraplegia.  Paralysis  of  the  lower  half  of  the  body, — both  legs  and  possibly  the  pelvic 
organs. 

Paresis.     Incomplete  or  partial  paralysis. 

Parkinson's  Disease.  "  Shaking  palsy.     Paralysis  agitans. 

Parosmia.  Unpleasant  subjective  sensations  of  smell,  or  a  perversion  of  the  apprecia- 
tion of  the  odors  commonly  encountered.  This  condition  is  usually  ob- 
served in  hysteria  and  insanity;  and  also  during  an  epileptic  aura,  or  from 
organic  lesions  of  the  olfactory  nerve  or  brain. 

Peduncle.  A  term  commonly  applied  b)^  neurologists  to  bundles  of  fibres  which  con- 
nect the  hemispheres  of  the  cerebrum  and  cerebellum  with  adjacent  })arts, — 
as,  for  example,  the  cerebral  peduncles  (crura),  and  the  three  pair  of  cere- 
bellar peduncles. 

Perimeter.  An  instrument  for  the  determination  and  registration  of  the  visual  field 
of  a  patient. 

Piesmeter.  An  instrument  for  the  estimation  of  the  "  pressure-sense "  in  any  given 
part. 

Polar  Method.  The  form  of  application  of  galvanism  made  with  special  reference  to 
the  determination  of  the  individual  effects  of  the  postitive  or  negative 
pole. 

Polar  P»,eactions.  The  effect  of  the  closure  or  opening  of  the  galvanic  current  when 
either  pole  is  applied  to  a  nerve  or  muscle.  In  health,  the  reactions  so  ob- 
tained follow  a  recognized  sequence,  according  as  different  degrees  of  current- 
strength  are  employed. 

Poliomyelitis  Anterior.  Inflammation  of  the  cells  of  the  anterior  horns  of  the  spinal 
gray  matter.     The  so-called  "infantile  paralysis." 

Polydipsia.     Insatiable  thirst. 

Polyneuritis.     Disseminated  neuritis.     Multiple  neuritis. 

Polyphagia.     Voracity.     Excessive  hunger. 

Posterior  Longitudinal  Bundle.  A  bundle  of  fibres  supposed  by  Spitzka  to  assist  in 
bringing  into  harmony  the  corpora  quadrigemina,  the  nuclei  of  the  fourth 
and  sixth  nerves,  and  those  which  govern  muscles  of  the  neck  (Fig.  11). 

Postero-external  Column.     See  GoU's  Column. 

Postero-median  Column.  A  term  applied  by  Gowers  to  the  column  of  Burdach.  See 
Burdock's  Column. 

Post- paralytic  Rigidity.  A  state  of  contracture  which  often  develops  in  muscles  after 
an  attack  of  paralysis. 

Presbyopia.     Failure  of  the  power  of  accommodation  due  to  age. 

Projection  Systems.  A  classification  of  the  various  bundles  of  fibres  which  serve  to 
unite  component  parts  of  the  nervous  system. 

Prosopalgia.     Facial  neuralgia. 

Peosopodysmorphia.     Progressive  facial  hemiatrophy. 


750  GliOSSARY. 

I'sYCHiCAL  BLiNnxnss.     An   iiialiililv  to  [iroppily  iiiterprot  visual  perceptions,  due  to  a 

lesion  of  tlie  cortex  of  the  occij>ital  lobes  of  the  ccrehruiu. 
Ptosis.     Inability  to  prevent  a  failing  of  the  up[)er  lid  over  the  eyeball.     Paralysis  of  the 

levator  palpf^bne  superioris  muscle. 
PuLViNAR.     The  posterior  tubercle  of  the  optic  thalamas.    It  is  believed  to  be  functionally 

associated  with  the  optic  fibres. 
Pl'Ncta  Dolorosa.     Points  of  tenderness  clinically  observed  along  the  course  of  nerve- 

tninks  affected  with  neuralgia.     They  were  first  described  by  Valleix. 
Pupillary  REFLf:x.     The  contraction  of  the  pupil  caused  by  an  excess  of  light  entering 

the  eye.     It  is  to  be  distinguished  from  the  contraction  of  the  jiupil  observed 

when  near  objects  are  focused  upon  the  retina. 
Purkinje's  Cp:lls.     A  form  of  cell  peculiar  to  the  cerebellar  cortex. 
Pyramidal  Tracts.     Fibres  which  are  so  called  because  they  j)ass  through  and  compose 

the  anterior  pyramids  of  the  medulla  oblongata.     They  are  probably  func- 
tionally associated  exclusive!}'  Avith  motor  impulses  (Fig.  29). 
QfiXTi's  Tract.     The  ascending  root  of  the  trigeminus  nerve  (Fig.  11). 
1\ail\vay  Paralysis.     Spinal  concussion.     Erichsen's  "railway  .s{)inal  affection." 
Kaphania.     Ergot  poisoning. 
Reaction  of  Degeneration.      Abnormal  electrical  formulae  of  the  so-called  "  muscular 

reactions  to  galvanic  currents."     This  is  also  as.sociated  with  an  impairment 

or  a  total  loss  of  faradaic  excitability  of  nerve  and  muscle. 
Red  NrcLEi.     Two  collections  of  cells  in  the  "tegmentum  cruris,"  which  are  structurally 

associated  with  the  superior  cerebellar  ])eduncles  (Fig.  11). 
Reflex  Action.     A  sensory  impression  transformed  into  a  motor  im^iulse. 
Respir.\tory  Bundle.     See  Hound  Bundle. 
Restiforji  Body.     The  inferior  peduncle  of  the  cerebellum.     The  so-called  "processnfe 

cerebello  ad  rnedullam." 
Reticular  Ganglion.     A  term  apjilied  by  Spitzka  to  the  gray  matter  of  the  "  formatio 

reticularis"  of  the  pons  and  medidla  oblongata  (Fig.  27). 
Rheophores.     The  cords  of  an  electrical  batter}-  which  are  employed  to  connect  the  poles 

with  the  electrodes  during  an  electrical  application. 
Robertson's  Pupil.     A  failure  of  the  pupil  to  react  to  light  without  any  perceptible  im- 
pairment of  its  normal  reaction  during  the    accommodation  of  vision  for 

near  objects. 
Rolando's  Fissure.     The  fissure  which  separates  the  frontal  lobe  from  the  parietal  lobe 

of  the  cerebrum  (Fig.  4). 
Round  Bundle.     The    so-called   "  respiratory  bundle "  of   Krause  and  the    "  trineural 

bundle"  of  Spitzka.     A  oundle  of  fibres  withm  the  medulla  probably  as-so- 

ciated  with  ninth,  tenth,  and  eleventh  nerves. 
Sommering's  Yellow  Spot.     The  point  where  most  distinct  vision  is  afforded  by  the 

retina,  situated  about  two  lines  to  the  outer  side  of  the  entrance  of  the  optic 

nerve. 
Saltatory  Spasms.     A  dancing  or  hopping  of  the  body,  caused  by  uncontrollable  spasms 

of  the  muscles  of  the  lower  limbs,  back,  neck,  or  upper  limbs. 
Sclerosis.     A  morbid  condition   dependent  upon   an   increase  in  the  connective-tissue 

elements  of  an  organ  or  other  structures. 
Speech  Tract.     A  bundle  of  fibres  which  serves  to  join  the  cortical  coordinating  centre 

of  speech  (Broca's  centre)  with  those  nuclei  of  the  medulla  oblongata  that 

preside  over  the  various  movements  associated  with  articulate  speech  (Fig. 

Spider-cells  of  Deiters.  A  form  of  cell  which  belong  to  the  connective-tissue  forma- 
tion.    (Neuroglia.) 

Spinal  Segment.  A  disk  of  the  cord,  with  a  jmir  of  the  spinal  nerves  attached  to  it, — 
one  on  either  side  (Fig.  30). 

Status  Epilepticus.  A  state  characterized  by  continued  epileptic  convulsions  with 
scarcely  perceptible  intermissions. 

Strabismus.  A  condition  of  abnormal  deviation  of  the  visual  axes,  resulting  in  habitual 
diplopia,  of  which  the  patient  may  often  be  unconscious. 

Subjective  Symptoms.  Any  morbid  nervous  phenomenon  of  which  the  patient  is  him- 
self conscious. 

Subependymal.     Situated  beneath  the  ependyma, — the  lining  of  the  ventricles. 

Sulcus.  A  line  of  demarcation  between  convolutions  of  the  cerebral  cortex.  Less  deep 
and  more  subject  to  variations  than  the  so-called  cerebral  "  fissures." 


! 


GLOSSAKY.  751 

Sylvian  Fissure.  The  fissure  containing  the  middle  cerebral  artery  and  separating  the 
parietal  from  the  temporal  lobes  of  the  cerebrum  (Fig.  4). 

Syringomyelia,     (cavities  within  the  substance  of  the  spinal  cord. 

Tabes  Dorsalis.     Locomotor  ataxia.     Posterior  spinal  sclerosis. 

Tegmentum  Cruris.     The  posterior  or  sensory  part  of  the  crus  cerebri  (Fig.  11). 

Tetanoid  Paraplegia.  A  type  of  paraplegia  associated  with  a  peculiar  rigidity  of  the 
muscles  and  exaggeration  of  the  spinal  reflexes. 

Tetanus  Neonatorum.  Infantile  tetanus,  following  umbilical  irritation,  ftecal  stasis,  puer- 
peral infection,  etc. 

Tetany.  Paroxysmal  tonic  muscular  spasms.  They  may  be  artificially  induced  by 
pressure  on  a  nerve-trunk  or  a  main  artery.     (Trousseau's  test.) 

Thomsen's  Disease.  Primary  spinal  muscular  spasm.  Attempts  at  voluntary  move- 
ments are  suddenly  hindered  or  interrupted.     A  hereditary  affection. 

Thrombosis.     Occlusion  of  a  blood-vessel  by  a  coagulum  formed  at  the  seat  of  occlusion. 

Tic-convulsif.     Diffuse  clonic  facial  spasm. 

Tic-DOULOUREUX.     Neuralgia  of  the  facial  nerve. 

Triangular  Nucleus.  A  collection  of  cells  which  are  structurally  related  to  the  fibres 
of  Burdach's  columns,  and  in  which  they  probably  end.  This  nucleus 
'(together  with  the  clavate  nucleus)  probably  gives  origin  to  some  of  the 
fibres  of  the  fillet  tract  (Fig.  12). 

Trineural  Bundle.  A  term  applied  to  the  round  bundle  of  the  medulla  by  Spitzka. 
See  Round  Bundle. 

Trochlear.  Relatmg  to  a  pulley.  The  superior  oblique  muscle  of  the  eye  is  so  called 
because  it  works  through  a  pulley. 

Turck's  Column.     Tlie  so-called  "direct  pyramidal  column"  of  the  spinal  cord  (Fig.  29). 

Will-tract.  A  term  employed  by  Spitzka  as  synonymous  with  the  pyramidal  tracts. 
See  Pyramidal  Tracts,  and  Fig.  12. 

Word-blindness.  A  loss  of  ability  to  properly  interpret  ordinary  sight-perceptions, — 
chiefly  the  meaning  ot  printed  and  written  characters.  It  must  not  be  con- 
founded with  actual  blindness. 

WoED-DEAFNESS.  A  loss  of  ability  to  properly  interpret  ordinary  sound-perceptions,  such 
as  the  meaning  of  spoken  language,  etc.  It  must  not  be  confounded  with 
deafness,  where  sounds  are  not  perceived  on  account  of  some  defect  in  the 
apparatus  of  audition. 


i 


\ 


BIBLIOGEAPHY. 


Aberceombie,  J.  0.      "Observations   in  Diseases  of  the  Spinal  Marrow."     Edinburgh 
Medical  and  Surgical  Journal,  1818. 
"  Researches  on  Diseases  of  the  Brain  and  Spinal  Cord."     Edinburgh,  1829. 
Adamkiewicz,  a.     "Die  Blutgefasse  des  menschlichen  Riickenmarkes."     Stzsbrct.  der  k. 

Akad.  der  Wiss.     Wien,  1881. 
Aldridge,  C.     "  The  Ophthalmoscope  in  Mental  and  Cerebral  Diseases."     West  Riding 

Lunatic  Asylum  Reports,  vol.  i.     London,  1871. 
Alexander,  R.  G.     "  Practical  Notes  on  Neuralgia  and  its  Treatment."     Lancet,  June  3, 

1882. 
Allbeett.     "  Migraine."     Practitioner,  x,  1873,  p.  25. 
Althaus,  J.     "Diseases  of  the  Nervous  System."     New  York,  1878. 

"  Paraplegia  from  Pott's  Disease."     Jour.  Nerv.  and  Ment.  Dis.,  1887. 
"Sclerosis  of  the  Spinal  Cord."     New  York,  1885. 
Amidon,  R.  W.     "  The  Effect  of  Willed  Muscular  Movements  on  the  Temperature  of  the 
Head."     Archives  of  Medicine,  April,  1880. 
"Cerebral  Thermometry."     Medical  Record,  Dec.  25,  1880. 
"  The  Myography  of  Nerve  Degeneration  in  Animals  and  Man."     Archives  of 

Medicine,  Aug.,  1882. 
"  Manual  of  Electro-Therapeutics."     New  York,  1884. 
Amoey,  R.     "Treati.se  on  Electrolysis."     New  York,  1886. 
Anderson,  M.  C.     "  A  Case  of  Myelitis."     Edin.  Med.  Jour.,  August,  1881. 
Anstie,  F.  E.     "  Neuralgia  and  the  Diseases  that  Resemble  it."     London,  1871. 
Arndt,  R.     "Studien  iiber  d.  Architek.  der  Grosshirnrinde  des  Menschen."     1868, 
Axenfeld,  a.  (Huchard).     "  Traite  des  nevroses."     Paris,  1883. 
Ayres,  W.  C.     "Eye   Diseases:   their  Bearings  upon  General   Diagnosis."      Am.  Jour. 

Med.  Sci.,  1882. 
AzAM,  M.     "  Amnesie  periodique  ou  dedoublement  de  la  vue."     Annales  medico-psychol- 

ogiques,  1876. 
Baker,  F.     Articles  on  the  "Cranial  Nerves"  and  on  the  "  Face."     Ref  Hand-book  Med. 

Sci.,  New  York,  1886. 
Ball,  Benjamin.     "  On  Certain  Cases  of  Functional  Ischemia  of  the  Brain."     Brit.  Med. 

Jour.,  1880. 
Bangs,  L.  B.    "  Neuroses  of  the  Genito-Urinary  System."    New  York  Med.  Monthly,  1886. 
Barker,  L.  W.     "The  Care  of  Epileptics."     New  Eng.  Med.  Monthly,  1884. 
Bastian,  H.  C.     "  Paralysis  from  Brain  Diseases."     New  York,  1875. 

"  The  Organ  of  the  Mind."     London,  1880. 
Bauer,  I.     Article  on  "Tetanus."     Ziemssen,  vol.  xiv. 
Beard,  G.  M.     "  American  Nervousness."     New  York,  1882. 

"  Neurasthenia."     New  York,  1880. 
Beard  and  Rockwell.     "  Treatise  on  Electricity."     New  York,  1884. 
Beevor,  C.  E.     "  Case  of  Glosso-Labial  Paralysis  with  Progressive  Muscular  Atrophy  and 
Lateral  Sclerosis."     Brain,  Oct.,  1882. 
Article  on  "  The  Knee-jerk,"  etc.     Brain,  1882. 
Bennett,  A.  H.     "  Bulbo-Spinal  Atrophic  Paralysis."     Brit.  Med.  Jour.,  March,  1884. 

"Chronic  Atrophic  Spinal  Paralysis  in  Children."     Brain,  October,  1883. 
Bernard,  Claude.     "  Recherches   experimentales   sur  le  grand   sympathique."     Paris, 

1854. 
Bernhardt,  M.     "  Ueber  eine  der  Spinale  Kinderlahmung  ahnliche  Affection  Erwach- 
sener."     Arch.  f.  Psych.,  November,  1874. 
"  Beitrage  zur  Symptomatologie  und  Diagnostik  der  Hirngeschwiilste."     Berlin, 
1881. 
Bertalot,  H.     "  Ueber  Meningitis  Tuberculosa  bei  Thirdeur."     Jahrb.  f  Kinderheilk., 

ix.  1876. 
Billod,  E.     "  Des  maladies  mentales  et  nerveuses."     Paris,  1882. 
Birdsall.  W.  R.     "Ophthalmoplegia  Externa."     Jour.  Nerv.  and  Ment.  Dis.,  1887. 
"  Tumors  of  the  Encephalon."     Jour,  of  Nerv.  and  Ment.  Dis.,  1882. 

48  (753) 


754  BIBLIOGRAPHY. 

Blandford,  G.  F.     "  Insanity  and  its  Treatment."     New  York,  1886. 
Bouchard.     "  Nouvelles  recherches  sur  I'hernorrhagie  cerebrale."     Paris. 
Bourdon,  M.     "  Recherches  clinioues  sur  les  centres  moteurs."     Paris,  1877. 
BouRNEViLLE.     "  Louise  Lateau,'   etc.     Paris,  1875. 

"Etudes   cliniques  et  thermometriques   sur  les  maladies  du  systeme  nerveux." 

Paris,  1872. 
"Recherches    cliniques    et   therapeutiques   sur  I'epilepsie  et  I'hysterie."     Paris, 

187H. 
"  Recherches  sur  I'epilepsie,  I'hyst-erie  et  I'idiotie."     Paris,  1872. 
Bramwell,    Byron.     "Clinical   Lectures   on   Intracranial  Tumors."     Edinburgh   Med. 
Journ.,  188L 
"  The  Diseases  of  the  Spinal  Cord."     New  York  :  Wm.  Wood  &  Co.,  1885. 
Bridge,  N.     Article  on  "Headache."     Ref.  Hand-book  Med.  Sci.,  New  York,  1886. 
Broadbent,  Wm.  H.     "  Ingravescent  Apoplexy,  a  Contribution  to  the  Localization  of 
Cerebral  Lesions."     Med,  Chir.  Trans.,  59,  1876. 
"  Aphasia."     London,  1868. 
Broca,  p.     "  Localisations  cerebrales."     Revue  d'anthropol,  1879. 

Brown-Sequard,  C.  E.     "  Lectures  on  the    Physiology  and    Pathology  of  the    Central 
Nervous  System."     Philadelphia,  1860. 
"  Lectures  on  the   Principal   Forms  of  Paralysis  of  the   Lower  Extremities." 
London, 1881. 
Brubaker    a.  p.      "  Dental  Irritation  in  Epilepsy."      Jour,  of  Nerv.  and  Ment.  Dis., 

Feb.,  1888. 
BuLLARD  W.  N.     Articles  on  "  The  Corpora  Quadrigemina  "  and  "  The  Dynamometer." 

Ref.  Hand-book  Med.  Sci.,  New  York,  1886. 
Butler,  I.     "  Electro-Therapeutics."     New  York,  1880. 

Buzzard,  T.     "Locomotor  Ataxy,  with  Anomalous  Joint  Affections."     Lancet,  1874. 
Calmeil,  L.  F.     "  Traite  des  maladies  inflammatoires  du  cerveau."     Paris,  1859. 
Carre,  M.     "De  I'ataxie  locomotrice  progressive."     These,  Paris,  1862. 
Carville,  C,  et  Duret,  H.     "  Note  sur  une  lesion  pathologique  du  centre  ovale  chez 
un  chien."     Arch,  de  physiol.,  1875. 
"  Sur  les  fonctions  des  hemispheres  cerebraux."     Arch,  de  physiol.,  1875. 
Case,  M.     "  Spinal  Diseases  and  Spinal  Curvature."     Medical  Record,  December,  1884. 
Cattell,  I.  M.     "  The  Time  it  takes  to  See  and  Name  Objects."     Mmd,  January,  1886. 
Cayley,  W.     "Gliomatous  Tumor  of  the  Brain."     Transac.  Pathol.  Society  of  London, 

vol.  xvi. 
Chairon.     "  Etudes  cliniques  sur  I'hysterie."     Paris,  1870. 
Chapin,  C.  V.     "The  Sympathetic  Nerve:  its  Relations  to  Disease."     Fiske-Fund  prize 

essay,  Providence,  1881. 
Chapman,  J.     "  Neuralgia  and  other  Diseases  of  the  Nervous  System."     London,  1873. 
Charcot   et   Bouchard.     "  Nouvelles   recherches    sur  la   pathogenic   de   I'hernorrhagie 

cerebrale."     Arch,  de  physiol.,  1868. 
Charcot   et  Gombault.     "Note  sur  un  cas  d'atrophie   musculaire   progressive   spinale 

protopathique."     Arch,  de  physiol.,  1875. 
Charcot,  J.  M.     "  Lectures  on  the  Diseases  of  the  Nervous  System."     2d  series.     New 
Sydenham  Soc, 1881. 
"  Lectures  on  Localization  in    Diseases  of  the  Brain."      Translated  by   E.   P. 

Fowler.     New  York,  1878. 
"  Lectures  on  the  Localization  of  Cerebral  and  Spinal  Diseases."    New  Sydenham 

Soc,  1883. 
"  Diseases  of  Old  Age."     New  York,  1882. 
Charrier,  Dr.  A.     "  Hemorrhagie  du  bulbe  rachidien."     Archives  de  physiologie,  1869. 
Cheesman,  W.  S.     "Article  on  Hallucinations  and  Illusions."     Rep.  Hart.  Med.  Sci. 
Clarke,  J.  L.     "Case  of  Disease  of  Spmal  Cord."     Arch,  of  Med.,  London,   1863,  vol. 
iii,  p.  1. 
"Researches  in  the  Structure  of  the  Brain."     1867. 
Clevenger,  S.  V.     "  Cerebral  Anatomy  Simplified."     Chicago  Medical  Journal  and  Ex- 
aminer, November,  1880. 
"Cerebro-Spinal  Nervous  System."     Journal  of  Nervous  and  Mental  Diseases, 

October,  1880. 
"  The  Sulcus  Rolando  and  Intelligence."     Journal  of  Nervous  and  Mental  Dis- 
eases, April,  1880. 
Clymer,  Meridith.     "  Lectures  on  the  Palsies."     Med.  Record,  1870.  M 


I 

1 


BIBLIOGKAPHY.  755 

CoMEGYS,  C.  G.     "  Facial  Paralysis  and  Labarinthine  Vertigo."     Med.  Record,  April  24, 

1880. 
Conner,  P.  S.     Article  on  "  Tetanus."     Pepper's  Syst.  Pract.  Med. 
CoRNiL,  V.     "Pathol.  Histologique."     Paris. 
Corning,  J.  L.     "  Brain  Exhaustion."     N.  Y.  Med.  Jour.,  December,  1883. 

"Electrization  of  Cerv.  Sympathetic    with  Carotid  Compression."     N.Y.Med. 

Jour.,  February,  1884. 
"  Pathology  and    Therapeutics   of  Epilepsy."     Jour,   of  Nervous   and   Mental 
Diseases,  1883." 
Cruveilhier,  J.     "  Anatomie  Pathologique." 

Dalton,  I.  C.     "  The  Cortical  Centres  of  Vision."     Med.  Record,  1881. 
Dana,  C.  L.     "On  the  Use  of  Hydrobromic  Acid  in  Nervous  Afiections."     Jour,  of  Nerv. 
and  Ment.  Diseases,  1883. 
"Study  of  a  Case  of  Anencephaly."     Jour,  of  Nerv.  and  Ment.  Dis.,  Jan.,  1888. 
"  Thomsen's  Disease."     Jour,  of  Nerv.  and  Ment.  Dis.,  April,  1888. 
Dawson,  Y.     "  Tubercular  Meningitis  in  an  Infant."     London  Lancet,  A]iril  12,  1884. 
Day,  W.  H.     "Headaches:  their  Nature,  Causes  and  Treatment."     Philadelphia,  1883. 
Deecke,  T.     "  Pathology  of  Sunstroke."     Am.  Jour.  Insanity,  October,  1883. 
"  Progressive  Meningo-Cerebritis."     Am.  Jour.  Insanity,  April,  1883. 
"  Traumatic  Epilepsy."     Am.  Jour.  Insanity,  April,  1883. 
De  Boismont.     "  History  of  Dreams,  Visions,  etc."     Philadelphia,  1835. 
Delasiaures.     "  Traite  de  lepilepsie."     Paris,  1854. 

Delay  AN,  D.  B.     "  Localisation  des  corticalen  motorischen  centrum  des  larynx."     1883. 
De  Watteville,  A.     "  Medical  Electricity."     Nev/  York,  1884. 
DoDDS,  W.  J.     "  On  the  Localisations  of  the  Functions  of  the  Brain," — being  an  Historical 

and  Critical  Analysis  of  the  Question.     Jour,  of  Anat.  and  Physiol.,  1878. 
Dowse,  T.  S.     "  The  Brain  and  its  Diseases."     London,  1879. 
Drozda,  Jos.  V.     "  Statistische  Studien  uber  die  Hsemorrhagia  Cerebri."     Wien.  Med. 

Presse,  March  7,  1880. 
Deummond,  D.     "  Diseases  of  the  Brain  and  Spinal  Cord."     London,  1883. 
Duchenne,  G.  B.     "  De  I'electrisation  localisee."     3me  edit.     Paris,  1872. 
Dujardin-Beaumetz.     "  A  Lecture  on  the  Treatment  of  Meningitis."     N.  Y.  Med.  Jour., 
August  11,  1883,  p.  141. 
"De  la  myelite  aigue.'      Paris,  1872. 
DuEAND,  C.     Des  aneurysmes  du  cerveau,  consideres  principalement  dans  leurs  rapport 

avec  I'hemorrhage  cerebrale."     Paris,  18H8. 
Duret,   H.     Recherches    anatomiques    sur    la    circulation   de  I'encephale."      Arch,   de 
physiol.,  normal  et  pathol.,  1874. 
"  Traumatismus  cerebraux."     These,  Paris,  1878. 
Duval,  M.     "  Recherches  sur  I'origine   ruUe  des  nerfs   craniens."     J.  de  I'anat.  et  de 

la  physiol.,  xii-xvi,  1876-80. 
EccHEVERiA,  M.  G.     "  Epilepsy."     New  York,  1870. 

Ecker,  a.     "  The  Cerebral  Convolutions  of  Man."     Translated  by  Robt.  T.  Edes,  1873. 
Edes,   R.   T.     Articles   on    "Cerebral    Hemorrhage,"   "Cerebral    Softening,"    "Cerebral 
Paralysis,"  "  Cerebral  Thrombosis  and  Embolism."  Pepper's  Syst.  Pract,  Med. 
Edinger,    L.      "Vorlesungen   tiber   den    Bau   der    Centralorgane    des    Nervensystems." 

Leipzig,  1885. 
EiCHHOEST,  H,     "Diseases  of  the  Nerves  and  Muscles."     New  York,  1886. 

"  Beitr.  zur  Lehre   von  der  Apoplexie  in  die  Riickenmarkssubstanz."     Charite- 
Annalen,  1874. 
EiSENLOHR,  C.     "  IJeber  acute  Bulbar-  und  Pons-affectionen."     Arch.  f.  Psych,  u.  Ner- 

venkr.,  ix  u.  x. 
EiSENMANN.     "  Die  Bewegungs- Ataxic."     Wien,  1863. 
Eliot,  Gustavus.     "  Poliomyelitis  Anterior  in  Adults."     American  Journal  of  Medical 

Sciences,  January,  1885. 
Erb,  W.  H.     "  Diseases  of  the  Peripheral  Cerebro-Spinal   Nerves."     Ziemssen's  Cyclo- 
pedia, vol.  XI. 
"Die  Thomsen'sche  Krankheit."     (Myotonia  Congenita.)     Leipzig,  1886. 
"Electro-Therapeutics."    New  York,  1885. 
"Diseases  of  Spinal  Cord  and  Medulla  Oblongata."     Ziemssen's  Cyclopedia,  vol. 

xiii. 
"Ueber  die  Juvenile   Form  der  Progressive  Muskelatrophie."     Deut.  Arch.  f. 
Kl.  Med..  1884. 


756  BIBLIOGRAPHY. 

EuLENBURO,  A.     Article  on  "Catalepsy."     Ziemssen's  Cyclopedia,  vol.  xiv. 

"  Lehrhuch  der  functionellen  Norveiikraiikheiten."     Berlin,  1871. 

"  Vaso  Motor  and  Trophic  Neuroses."     Ziemssen's  Cyclopedia,  vol.  xiv. 
ExNER,  S.     "  On  Cerebral  Localization."     Jour,  of  Pliys.,  1882. 

"  Untersucliungen  iiber  die  Localisation  <ler  Functionen  in  der  Grosshirnrinde  de8 
Men!5chen."     Wien,  1881. 
Fagge,  C.  H.     "  Principles  and  Practice  of  Medicine."     Philadelphia,  1886. 
Fardel,  D.     "  Traite  pratique  des  maladies  des  vieillards."    Paris,  1854. 
Fenger,  Christian.     "  On  Opening  and   Drainage  of  Abscess  Cavities  in  the  Brain." 

Am.  Jour,  of  the  Med.  Sci.,  July,  1884. 
Fere,  Ch.     "Contribution  a  I'etude  des    troubles  fonctionnels  de    la  vision  par  lesions 

cerebrates."     Paris,  1882. 
Ferrier,  D.     "  Experimental  Researches  in  Cerebral  Physiology  and  Pathology."     West 
Riding  Asylum  Med.  Rep.,  1873. 

"  Functions  of  Brain."     New  York,  1886. 

"  Localization  of  Cerebral  Diseases."     New  York,  1879. 
Finney,  J.  M.     "Clinical  Remarks  on  Cases  illustrating  the  Essential  Identity  of  Pro- 
gressive Muscular  Atrophy  and  Progressive  Bulbar  Paralysis."     Brit.  Med.  Jour., 

June,  1884. 
Flechsig,  p.     "  Die  Leitungsbahnen  im  Gehirn  u.  Riickenmark  des  Menschen."     Leipzig, 
1876. 

"Plan  des  Mensch.  Gehirns."     Leipzig,  1884. 
Flourens,  M.     "  Recherches  experimentales  sur  les  proprietes  et  les  fonctions  du  systenae 

nerveux."     Paris,  1842. 
FoLSOM,  C.  F.     Article  on  "Mental  Diseases."     Pepper's  Syst.  Pract.  Med. 
Foster,  M.     "Text-book  of  Physiology."     Third  ed.     New  York,  1880. 
FoTHERGiLL,  J.  M.     "Cerebral  Antemia."     West  Riding  Hospital  Reports,  vol.  iv,  1874. 

"The  Physiological  Factor  in  Diagnosis."     New  York,  1883. 
Fox,  A.  W.      "Case  of  Progressive  Muscular  Atrophy  with  Bulbar  Paralysis."     Brit. 

Med.  Jour.,  Jan.,  1881. 
Fox,  E.  L.     "Path.  Anat.  of  Nerv.  Centres."     London,  1874. 

"Clinical  Lecture  on  Spinal  Hemorrhage."     Med.  Times  and  Gazette,  1876. 
Friedreich,  N.     "Ueber  progressive  Muskelatrophie."     Berlin,  1873. 
Fritsch  and  Hitzig.     "Ueber  die  electrische  Erregbarkeit  des  Grosshirns."     Reichart 

und  Du  Boi.s-Reymond's  Arch.,  1870. 
Frommann.     "Untersuch.    iiber  die   normals  u.  Pathol.  Anatomic  des  Riickenmarks." 

Jena,  1867. 
FucHS.     "  Beobachtungen  und  Bemerkungen  iiber  Gehirnerweichung."     Leipzig,  1838. 
Gardane.     "  Conject.  sur  I'electricite  med."     Paris,  18(i8. 
Gelpke,  Ottomar.     "  Vergleichende  Zusammenstellung  der  Symptome  von  Hirnapoplexie 

und  Embolic  der  Hinarterien."     Archiv  der  Heilkunde,  1875. 
GiBNEY,  V.  P.     "  Tiie  Treatment  of  Sciatica."     Med.  Rec,  June  7,  1884. 
GiNTRAC,  E.     "  Traite  theorique  et  pratique  des  maladies  de  I'appareil  nerveux."     Paris, 

1869. 
GoLTDAMMEE,  E.     "  Ein  Beitrag  zur  Lehre  von  der  Spinalapoplexie."    Virch.  Arch.,  Ixvi. 
GoMBAULT.     "  Note  sur  un  cas  de  jiaralysie  spinale  de  I'adulte,  suivi  d'autopsie."     Arch. 

de  physiol.,  1873. 
GoocH,  Dr.     "  Diseases  of  Women  and  Children,"  and  other  papers.      New  Sydenham 

Society,  London,  1859. 
GowEES,  W.  R.     "  Diseases  of  the  Brain  and  Spinal  Cord."     New  York,  1885. 

"Epilepsy  and  other  Chronic  Convulsive  Diseases."     New  York,  1885. 

"  On    Athetosis   and    Post-Hemiplegic   Disorders   of    Movement."      Med.   Chir. 
Trans.,  59,  1876. 

"  The  Diagnosis  of  Diseases  of  the  Spinal  Cord."     Philadelphia,  1884. 
Gradle,  H.     "Hypnotism."     Ref  Hand-book  Med.  Sci.,  New  York,  1886. 
(traham,  D.     "  Massage."     Ref.  Hand-book  Med.  Sci.,  New  York,  1886. 
Grasset,  J.     "  Localizations  dans  les  maladies  cerebrales."     1878. 

"  Maladies  du  systeme  nerveux."     1881. 
Graves,  R.  J.     "  Clinical  Lectures."     Philadelphia,  1838. 

Green,  J.     Articles  on  "  Astigmatism,"  "  Diplojiia,"  and  "Hypermetropia."     Ref.  Hand- 
book Med.  Sci.,  New  York,  1886. 
Green,  T.  H.     "Pathology  and  Morbid  Anatomy."     Pliiladeli  hia,  1871. 
Greidenberg,  B.     "  Post-Hemiplegic  Disturbances  of  Motion."     Arch,  fiir  Psych.,  xvii. 


i 


I 


i 


i 


BIBLIOGRAPHY.  (Oi 

Griesinger,  W.     "  Hsematom  der  Dura  Mater."     Arch.  d.  Heilkunde,  3,  Bd. 

"  Mental  Pathology  and  Therapeutics."     New  York,  1882. 
GuBLER.     "8ur  r  hemeplegie  alterne."     Gaz.  hebd.,  Oct.,  I80H. 
Gull.     "  Paraplegia  from  Obstruction  of  the  Abdominal  Aorta."      Guy's  Hosp.  Reports 

1858. 
Hallopeau,  H.     "  Etude  sur  les  myelite  chroniques  diffuses."    Arch.  gen.  de  med.,  Sept.. 

1871. 
Hamilton,  A.  McLean.      Articles  on   "  Facial    Hemiatrophy  "    and   "  Epilepsy."      Pi,ef. 

Hand-book  Med.  Sci.,  New  York,  188H. 
"  Localized  Convulsive  Diseases."     Pepper's  Syst.  Pract.  Med. 
"Nervous  Diseases:   their  Description  and  Treatment."     Philadelphia,  1881. 
Hamilton,  J.     "  Reflex  Paralysis  and  Urinary  Paraplegia."     Brit,  and  For.  Medico-Chir. 

Rev.,  187(i. 
Hammond,  G.  M.     "  Athetosis :  its  Treatment  and  Pathology."     Jour.  Nerv.  and  Ment. 

Dis.,  1886. 
Hammond,  W.  A.     "  A  Treatise  on  the  Diseases  of  the  Nervous  System."   New  York,  1881. 
"  Hereditary  Form  of  Locomotor  Ataxia."     Jour,  of  Nerv.  and  Ment.  Dis.,  1882. 
Hayem,  G.     "  Des  hemorrhagies  intrarachidiennes."     Paris,  1872. 
Henle,  J.     "  Handbuch  der  Nervenlehre  des  Menschen." 

"  Nervenlehre."     1876. 
Heubner,  0.     "Syphilis  of  Nervous  Syst."     Ziemssen's  Cyclopedia,  vol.  xii. 
Hewitt,  Graily.     "Chronic  Starvation."     London  Lancet,  Jan.  11,  1879. 
Hilton,  J.     "  Rest  and  Pain."     New  York,  1879. 
HiTziG,  E.     "  Untersuch.  iiber  das  Gehirn."     Berlin,  1874. 
Hollis,  W.  a.     "  Researches  into  the  Histology  of  the  Central  Gray  Substance  of  the 

Spinal  Cord  and  Medulla  Oblongata."     Journal  of  Anatomy  and  Physiol., 

July,  1883. 
Horsley,  V.      "Topography  of  Cerebral  Cortex."      Am.  Jour.  Med.  Sci.,  April,  1887; 

Journal  of  Nerv.  and  Ment.  Dis.,  May,  1887. 
HuGUENiN,  G.     "  Acute  and  Chronic  Inflammations  of  the  Brain  and  its  Membranes." 

Ziemssen's  Cyclopedia,  vol.  xii. 
"  Anatomie  des  centres  nerveux."     Paris,  1879. 
Humphrey,  Lawrence.     "Slow  Compression  of  the  Spinal  Cord."     Lancet,  Jan.  5,  1884, 

p.  14. 
Hun,  Henry.     "  Clinical  Study  of  Cerebral  Localization."    Am.  Jour.  Med.  Sci.,  January, 

1887. 
Inman,  T.     "  On  Myalgia."     London,  1860. 
Ireland,  W.  W.     "Idiocy  and  Imbecility."     London,  1877. 

"Blot  upon  the  Brain."  New  York,  1886. 
Jaccoud,  S.  "  Traite  de  pathologie  interne."  1870. 
Jackson,  J.  Hughlings.    "Clinical  and  Physiological  Researches  on  the  Nervous  System." 

Lancet,  1873. 
"Diagnosis  of  Tumor  of  Brain."     Med.  Times  and  Gaz.,  Aug.,  1873. 
"Ophthalmology  in  its  Relations  to  Medicine."     Lancet,  1877. 
Jacoby,  G.  W.     "  Massage  in  Nervous  Diseases."     Jour,  of  Nerv.  and  Ment.  Dis.,  Oct., 

1885. 
"Thomsen's  Disease."     Jour.  Nerv.  and  Ment.  Dis.,  1887. 
Jacobi,  Mary  P.     Articles  on  "Cerebral  Atrophy,'  "Cerebral  Malformations,"  and  "Cer- 
ebral Tumors."     Ref  Hand-book  Med.  Sci.,  New  York,  1886. 
"Loss  of  Nouns  in  Aphasia."     Jour.  Nerv.  and  Ment.  Dis.,  Feb.,  1887. 
Janeway,  E.  G.     "Cases    illustrating    Difficulties   in   Cerebral    Localization."     Jour,   of 

Neurol,  and  Psychiatry,  1882. 
JoPFEOY,  A.     "De  la  pachymeningite  cervicale  hypertrophique."     Paris,  1873. 
Jolly,  F.     "  Hysteria."     Ziemssen's  Cyclopedia,  vol.  xiv. 
Jones,  C.  H.     "Studies  of  Functional  Nervous  Disorders."     London,  1870. 
Kadner.     "  Zur  Casuistik  der  Riickenmarkscompression."     Arch,  der  Heilkunde,  1876, 

p.  481. 
Kahler,  0.     "Ueber  die  Verjinderungen  welche  sich  im    Riickenmarke  in  Folge  einer 

geringgradigen  compression  entwickeln."    Zeitschr.  f  Heilk.,  iii,  1882,  p.  187. 
Key  and  Retzius.     "Studien  in.  d.  Anat.  d.  Nervensyst."     Stockholm,  1875. 
KiRCHOFF.     "Cerebrale  Glosso-Pharyngo-Labial  Paralyese  mit  einseitigem  Herd."     Arch. 

f.  Psych,  u.  Nervenkr.,  xi,  1880,  p.  132. 
KiRSHABER,  Dr.  M.     "De  la  nervopathic  cerebro-cardiaque."     Paris,  1873. 


758  BIBLIOGRAPHY. 

KoEULER  AND  Spitzka.     "Relation  of  Miliarj'  Aneurisms  of  Spinal  Cord  to  Hereditary 
Spinal  Neuroses,  simulating  Multijtle   Sclerosis."     N.  Y.  Med.  Jour.,  April, 

"Chloroform  Diffusion  by  the  Anode  in  Neuralgia."     Med.  Record,  April,  1887. 
Kremiansky,  Jacob.     "  Ueber  die  Pachymeningitis  interna  haemorrhagica  bei  Menschea 

und  Hunden."     Virch.  Arch.  42,^  1868,  pp.  129  and  321. 
Krause,  W.     "  Handb.  d.  menschl.  Anatomie."     1876. 
Kussmaul,  a.     "Disturbances  of  Speech."     Ziemssen's  Cyclopedia,  vol.  xii. 

"  Ueber  die  fortschreitende  Bulbarparalysen  und    inr  Verhaltniss  zur  progres- 

siven  Muskelatrophie."     Volkmann's  kl.  Vortrage,  No.  54,  1873. 
Kussmaul  and  Tenner.     "  Epileptiform  Convulsions  after  Bleeding."     New  Sydenham 

Soc,  1859. 
Ladame,  Paul.     "  Symptomatologie  und  Diagnostik  der  Hirngeschwiilste."     1865. 
Lancereaup,  E.     "  De  la  thrombose  et  de  I'embolie  cerebrales  considerees  principalement 

dans  leurs  rapports  avec  le  ramoUissement  du  cerveau."     Paris,  1862. 
Langsberg,  M.    "  Affections  of  the  Eye  in  Hysteria."    Jour,  of  Nerv.  and  Ment.  Dis.,  1886 
Langley,  J.  N.     "  Nerve-tracts  of  Spinal  Cord."     Critical  Account.     Brain,  April,  1886. 
Lemoine,  G.,  and  Lannois,  N.     "  Perimeningite  spinale  aigue."     Revue  de  med.,  No.  6, 

1882. 
IjEURet,  F.     "  Essai  sur  la  congestion  cerebrale."     Paris,  1858. 
Lewes,  G.  H.     "  Physical  Basis  of  Mind."     London,  1877. 
Lewis,  W.  B.     "  The  Human  Brain."     London,  1882. 
Leyden,  E.     "  Klinik  der  Riickenmarkskrankheiten."     Berlin,  1874. 

"  Zur  progressiven  Bulbarparalyse."     Arch.  f.  Psych,  u.  Nervenkr.,  ii,  iii. 
Lidell,  J.  A.     "  A  Treatise  on  Apoplexy,  Cerebral  Hemorrhage,  Cerebral  Embolism,  etc." 

New  York,  1873. 
Lincoln,  R.  P.     "  A  Case  of  Melano-Sarcoma  of  the  Nose  Cured  by  Galvano-Cauteriza- 

tion."     New  York  Med.  Jour.,  Oct.,  1885. 
LiREiNG,  E.     "  Migraine."     London,  1873. 

Lisle.     "  Du  traitement  de  la  congestion  cerebrale."     Paris,  1871. 
Lloyd,  J.  H.     "  Tumors  of  the  Cord  and  its  Envelopes."     Pepper's  Syst.  Pract.  Med. 
Loomis,  a.  L.     "  Practical  Medicine."     New  York,  1884. 
Longet,  F.  a.     "  Anatomie  et  physiologic  du  systeme  nerveux."     Paris,  1842. 
IjUciani,  L.,  und  Seppilli,  G.      "  Die   Functions-Localisation   auf  der   Grosshirnrinde." 

Leipzig,  1886. 
LuYS,  J.     "  The  Brain  and  its  Functions."     New  York,  1881. 
Lyman,  H.  M.     "  Insomnia  and  Disorders  of  Sleep."     Chicago.  1885. 
McMuNN,  C.  A.     "  Notes  on  a  Case  of  Spinal  Apoplexy."     Dublin  Jour,  of  Med.  Sci., 

March,  1880. 
Magnan,  M.     "  Memoires  de  la  societe  de  biologie."     Paris,  1869. 
Malassez,  M.     "  Lead  Palsy."     Lancet,  May,  1874. 
Macabian,  Jean,  Firmin.     "  Quelques  cons. derations  sur  les  tumeurs  du  cervelet."    Paris, 

1869. 
Marsh,  H.     "  On  the  Diagnosis  of  Caries  of  the  Spine  in  the  Stage  preceding  Angular 

Curvature."     Brit.  Med.  Jour.,  June,  1881. 
Martin,  F.  H.     "  Electrolysis  in  Gynecology."     Jour,  of  the  Am.  Med.  Ass.,  July,  1886. 
Mattison,  J.  B.     "  Galvanism  for  Relief  of  Neuralgic  Pain."    Canadian  Practitioner,  1885. 
Mayer.     "  Zur  Lehre  von  der  Aniimie  des  Riickenmarks."     Zeitschr.  f.  Heilk.,  1883. 
McNutt,  S.  J.     "  Apoplexia  Neonatorum."     Am.  Jour.  Obstet.,  Jan.,  1885. 

"  Double  Infantile  Spastic  Hemiplegia."     Am.  Jour.  Med.  Sci.,  Feb.,  1885. 
"  Infantile  Spastic  Hemiplegia."     Archives  of  Pediatrics,  Jan.,  1885. 
Meissner.     "  Berichte  liber  Embolien  und  Yrombosen."     Schmidt's  Jahrb.,  1874. 
Meyer,  R.     "  Zur  Pathologic  des  Hirnabscesses."     Zurich,  1867. 
Meynert,  T.     "  The  Brain  of  Mammals;"  "Strieker's  Histology;"  "Psychiatry."     New 

York,  1885.     (Translated  by  Sachs.) 
Mickel.     "  Die  Cellular  Pathologic."     Berlin,  1871. 
Mills,  C.  K.     Articles   on    "  Hysteria,"    "  Catalepsy,"    "  Hystero-Epilepsy,"    "  Ecstasy," 

and  "  Tumors  of  Brain."     Pepper's  Syst.  Pract.  Med. 
"  Epileptoid  Varieties  of  Hystero-Epilepsy."     Jour.  Nerv.  and  Ment.  Dis.,  1882. 
MiNOT,  F.     Articles  on  "Disease  of  Cerebral  Meninges"  and  "Disease  of  Spinal  Me- 
ninges."    Pepper's  Syst.  Pract.  Med. 
Mitchell,  S.  Weir.     "  Fat  and  Blood."     Philadelphia,  1877. 

"  Injuries  of  Nerves  and  their  Consequences."     Philadelj^hia,  1872. 


i 


BIBLIOGRAPHY.  759 

Morton,  W.  J.     "  Nerve-stretching."     Jour.  Nerv.  and  Ment.  Dis.,  1882. 

"Static  Electricity."     Med.  Record,  1881. 
MoTTA,  E.  A.     "  Ueber  Hirnaniimie  im  Allgemeinen  und  insbesondere  iiber  Blutleere  des 
Gehirns  und  liber  de.ssen  consecutive  Erweichung."     Deutsche  Klinik,  1874. 
MoxoN,  Walter.     "  Influence  of  the  Circulation  upon  the  Nervous  System."     Brit.  Med. 

Jour.,  1881. 
MuNDE,  P.  F.     "  Electricity  as  a  Therapeutical  Agent  in  Gynecology."      Am.  Jour,  of 

Obs.,  and  Dis.  of  Women  and  Children,  Dec,  1885. 
MuNK,  H.     "  Ueber  die  Functionen  der  Grosshirnrinde."     Berlin,  1887. 
Naether,  R.     "  Die  metastatischen  Hirnabscesse  nach  primiiren  Lungenherden."     Deut. 

Arch.  Kl.  Med.,  1883. 
NoTHNAGEL,  H.     "Anaemia,  Hyperaemia,  Hemorrhage,  Thrombosis,  and  Embolism  of  the 
Brain."     Ziemssen's  Cyclopedia,  vol.  xii. 
"  Epilepsy."     Ziemssen,  vol.  xiv. 

"  Topische  Diagnostik  der  Gehirnkrankheiten."    Berlin,  1879. 
Obernier,  F.     "  Tumors  of  the  Brain  and  its  Membranes."     Ziemssen,  vol.  xii. 
Ollivier,  C.  p.     "  Traite  des  maladies  de  la  moelle  epeniere."     Paris,  1837. 
Ordenstein,  L.     "Sur  la  paralysie  agitante."     Paris,  1868. 
OsBORN,  H.  F.     Article  on  "  Cerebral  Development."     Ref.  Hand-book  Med.  Sci. 
Ott,  J.     "  Paths  of  the  Various  Fibres  of  the  Spinal  Cord."     Am.  Neur.  Soc,  June,  1884. 

"  The  Heat  Centre  in  the  Brain."     Jour.  Nerv.  and  Ment.  Dis.,  1884,  1887. 
Ott,  J.,  AND  Smith,  R.  M.     "  The  Paths  of  Conduction  of  Sensory  and  Motor  Impulses  in 
the  Cervical  Segment  of  the  Spinal  Cord."     Am.  Jour.  Med.  Sci.,  Oct.,  1879. 
Page,  H.  W.     "  Injuries  of  the  Spine  and  Spinal  Cord."     London,  1883. 
Parish,  J.     "  Spinal  Irritation."     Am.  Jour.  Med.  Sci.,  1832. 
Park,  Roswell.     Article  on  "  Electricity."     Ziemssen's  Supplement. 
Parkinson,  J.     "  Essay  on  the  Shaking  Palsy."     London,  1817. 

Petitfils,  a.     "  Considerations  sur  I'atroyihie  aigne  des  cellules  matrices."     Paris,  1873. 
Pinser,  J.  M.     "  On  the  Anatomy  and  Physiology  of  the  White  Tracts  of  the  Spinal 

Cord."     Dublin  Jour,  of  Med.  Sci.,  1878. 
Pitres,  a.     "  Lesions  du  centre  ovale."     These,  Paris,  1877. 
Pitres,  J.  A.     "  Recherches  sur  les  lesions  du  centre  ovale  des  hemispheres  cerebraux, 

etudiees  au  point  de  vue  des  localisations  cerebrale."     Versailles,  1877. 
Prichard,  J.  C.     "  A  Treatise  on  Diseases  of  the  Nervous  System."     London,  1822. 
Proust,  A.,  and  Ballet,  G.     "  Contribution  a  I'anatomie  pathologique  de  la  paralvsie 
generale  spinale  diffuse  subaigue  de  Duchenne."     Arch,  de  Physiol.,  Oct., 
1883. 
Putnam,  J.  J.     "  Chronic  Lead-Poisoning."     Jour.  Nerv.  and  Ment.  Dis.,  1887. 
Putnam,  J.  S.     Article  on  "Neuralgia."     Pepper's  Syst.  Pract.  Med. 
Putnam,  M.  J.     Article  on  "  Infantile  Spinal  Paralysis."     Pepper's  Syst.  Pract.  Med. 
PuTZEL,  L.     "Diseases  of  the  Brain  and  Medulla."     Ziemssen's  Supplement. 
"  Functional  Nervous  Diseases."     New  York,  1883. 

Articles  on  "  Cerebral  Abscess,"  "  Cerebral  Aneuresia,"  "  Cerebral  Hemorrhage," 
"Cerebral  Syphilis,"  "Cerebral  Embolism  and  Thrombosis,"  "  Facial  Neural- 
gias," "  Facial  Paralysis,"  and  "  Migraine."     Ref  Hand-book  Med.  Sci. 
Ranney,  A.  L.     "  Electricity  in  Medicine."     New  York,  1885. 

"  The  Applied  Anatomy  of  the  Nervous  System."     New  Y'ork,  1888.     2d  ed. 
"  An  Unique  Case  of  Poliomyelitis  Anterior  Acuta  of  the  Adult."     Archives  of 

Medicine,  Aug.,  1884. 
"  Eye-Strain  in  its  Relations  to  Neurology."     New  York  Med.  Jour.,  April  16, 

1887. 
"  Eye-Strain  in  its  Relation  to  Functional  Nervous  Diseases."     Med.  Bulletin, 

Sept.,  1887. 
"  Does  a  Relationship  Exist  between  Anomalies  of  the  Visual  Apparatus  and  the 

so-called  'Neuropathic  Predisposition?'  "     Med.  Register,  Nov.,  1877. 
"The  Architecture  of  the  Spinal  Cord  and  its  Relations  to  Medicine."      New 

York  Med.  Jour.,  1884. 
"  The  Treatment  of  Functional  Nervous  Diseases  by  the  Relief  of  Eye-Strain." 
N.  Y.  Med.  Jour.,  Jan  ,  1888. 
Ranvier,  L.     "  LeQons  sur  I'histologie  du  systeme  nerveux."     Paris,  1878. 
Remak,  E.     "  Elektro-diagnostik  und  Elektro-therapie."     1880. 

Roberts,  J.  B.     "  Field  and  Limitation  of  Operative  Surgery  of  the  Brain."     Philadel- 
phia, 1885. 


760  BIBLIOGEAPHY. 

Rosenthal,  M.     "  A  Olinical   Treatise   on   Diseases  of  Nervous  System,"  vol.   i.     New 

York,  1879.     (Translated  by  L.  Tulzel.) 
Ross,  James.     "  A  Treatise  on  the  Diseases  of  the  Nervous  System."     Two  vols.     New 
York,  1883. 
"  Labio-glosso-pharyngeal  Paralysis  of  Cerebral  Origin."     Brain,  1882. 
RossE,   J.  C.      Articles   on  "Aphasia,"  "Catalepsy,"  "Cerebral    Softening,"    "Cerebral 
IIyperifimia,"and  "  Cerebral  Comjiression."    Ref  Hand-book  Med.  Sci.,  vol.  i. 
Russell,  William.     "  The  Early  Diagnosis  of  Spinal  Caries."     Brit.  Med.  Jour.,  Nov., 

1881. 
Saghs,  B.     "  Contributions  to  Study  of  Tumors  of  the  Spinal  Cord,"     Jour.  Nerv.  and 

Ment.  Dis.,  Nov.,  1886. 
Sanders,  E.  A.     "  A  Study  of  Primary,  Immediate,  or  Direct  Hemorrhage  into  the  Ven- 
tricles of  the  Brain."     Am.  Jour.  Med.  Sci.,  July  and  Oct.,  1881. 
Sayre,  Lewis  A.     "  Spinal  Disease  and  Curvature."     London,  1877. 
ScHiEFFERDECKER.     "  Beitrage  zur  Kentniss  des  Faserverlauf  im  Riickenmark.     Arch.  f. 

Mikroskopisclie  Anatomic. 
ScHUPPEL,  O.     "  Ueber  Hydromyelus."     Arcliiv  der  Heilk.,  1865. 
Schuster.     "  Diagnostik  der  Riickenmarkskrankheiten."     Berlin,  18Si. 
ScHWALBE,  G.     "  Lehrbuch  der  Neurologie."       Hotfman's    Lehrbuch    der  Anatomic  des 

Menschen. 
Seguin,  E.  C.     Articles  on  "  Pathology  of  Hemianopsia  of  Central  Origin."     Jour.  Nerv. 
and  Ment.  Dis.,  Jan.,  1886,  and  Dec,  1887. 
"  Localization  of  Spinal  and  Cerebral  Diseases."     New  York  Med.  Record,  1878. 
"  Myelitis  of  the  Anterior  Horns."     New  York,  1877. 
*'  Spinal  Paralysis."     New  York,  1874. 

"Pathology  of  the  Cerebellum."     Med   Record,  March,  1887. 
"  The  Localization  of  Diseases  in  the  Spinal  Cord."     Opera  Minora,  New  York, 
1884. 
Seitz,  J.     "  Die  Meningitis  tuberculosa  der  Erwachsenen."     Berlin,  1874. 
SiEREKiNG,  E.  H.     "  On  Epilepsy,"  etc.     London,  1858. 
Sinkler,  W.     Articles  on  "Headache,"  "Tremor,"  "Paralysis  Agitans,"  "  Chorea,"  and 

"Athetosis."     Pepper's  Syst.  Pract.  Med. 
Skey,  F.  C.     "  Hysteria,"  etc.     London,  1866-67. 

Smith,  Priestly.     "  Bilateral  Deviation  of  the  Eyes."     Birmingham  Med.  Review,  1875. 

Smith,  W.  E.     "  Hereditary  or  Degenerative  Ataxia."     Boston  Med.  and  Surg.  Jour.,  Oct., 

1885. 

"  Postero-Lateral  Sclerosis  of  Generic  Origin."  Boston  Med.  and  Surg.  Jour.,  1888. 

Spencer,  W.  H.     "  Case  of  Idiopathic  Inflammation  of  the  Spinal  Dura  Mater."     Lancet, 

June,  1879. 
Spitzka,  E.  C.     "Anatomy  of  the  Lemniscus."     Med.  Record,  1881. 

"  Comparative  Anatomy  of  the  Pyramidal   Tract."     Jour,   of  Comp.  Med.  and 

Surg.,  1866. 
"Chronic  Inflammation  and  Degenerative  Affections  of  the  Spinal  Cord."     Pep- 
per's Svst.  Pract.  Med. 
"  Sensory  Tract  of  Brain  ; "  "  Functional   and  Morphological  Relations  of  the 

Cerebellum."     Chicago  Med.  Rev.,  1881. 
"  Architecture  of  the  Medulla."     N.  Y.  Med.  Jour.,  1881. 

"  Architecture  and  Mechanism  of  the  Brain  ;  "     "  The  Central   Tubular  Gray." 
Jour,  of  Nerv.  and  Ment.  Dis.,  1880. 
Starr,  M.  A.     "  Diagnosis  of  Lesions  of  the  Centrum  Ovale."     Med.  Record,  1886. 

"  Sensory  Tract  in  Central  Nervous  System."    Jour,  of  Nerv.  and  Ment.  Dis.,  1884. 
"  Lectures  on  Multifile  Neuritis."     Med.  Record,  Feb.,  1887. 
Article  on  "  Vaso-Motor  and  Trophic  Neuroses."     Pepper's  Svst.  Pract.  Med. 
"  Localization  of  Functions  of  Spinal  Cord."      Am.  Jour.  Neurol,  and  Psych., 

Nov.,  1884. 
"Speech."     Princeton  Review,  April.  ]SS6. 

"  Diagnosis  of  Local  Lesions  of  the  Brain."     Ref  Hand-book  Med.  Sci.,  vol.  i. 
Article  on  "  Hemianopsia."     Pv.ef  Hand-book  Med.  Sci. 
"The  Visual  Area  in  the  Brain  determined  by  a  Study  of  Hemianopsia."     Am. 

Jour.  Med.  Sci.,  Jan..  1884. 
"  Cortical  Lesions  of  the  Brain."     Am.  Jour.  Med.  Sci.,  July,  1884. 
Stevens,  G.  T.     "Functional  Nervous  Diseases."     New  York,  1887." 

"  Oculo-Neural  Reflex  Irritation."     Trans.  Internat.  Med.  Congress,  1881. 


BIBLIOGRAPHY.  761 

Stevens,  G.  T.     "Clinical  Notes  on  Neuralgia,  in  connection  with  Troubles  of  the  Accom- 
modation of  the  Eye."     Med.  Record,  Oct.,  1877. 
"  Light  in  its  Relation  "to  Disease."     N.  Y.  Med.  Jour.,  June,  1877. 
"Retractive  Lesions  and  Functional  Nervous  Diseases."     Medical  Record,  Sept. 

1876. 
"Irritations  arising  from  the  Visual  Apparatus,"  etc.     N.  Y.  Med.  Jour.,  April 

16,  1887. 
"  Anomalies  of  the  Ocular  Muscles."     Arch,  of  Ophthalmology,  vol.  xvi. 
Stilling,  B.     "  Untersuch.  lib.  d.  Textur.  u.  Funct.  der  Med.  Oblongata."    Erlangen,1843. 
Stirling,  William.     "  On  the  Reflex  Functions  of  the  Spinal  Cord."     Edinburgh  Med. 

Jour.,  April,  1876. 
Strumpell,  a.     "  Krankheiten  des  Nerven  System."     Leipzig,  1884. 

"  Zur  Casuistik  der  Apoplektischen  Bulbahmungen."     Deut.  Arch,  f  kl.  Med., 

1880. 
Tate.     "  Treatise  on  Hysteria."     London,  1830. 

Taylor,  C.  T.     "A  Home-made  Spinal  Apparatus."     N.  Y.  Med.  Jour.,  Sept.,  1886. 
Taylor,  H.  L.     "Paralysis  of  Pott's  Disease."     Med.  Record,  June,  1886. 
Thompson,  H.     "  Case  of  Cerebral  Abscess,"  etc.   Med.  Times  and  Gaz.,  March,  1878. 
Thomson,  W.  H.     "Prophylaxis  of  Hemiplegia."     N.  Y.  Med.  Record,  1878. 
Tooth.     "  Dorsal  Pachymeningitis."     Brain,  1884. 

ToRCK,  L.     "  Abhandlung  liber  Spinal  Irritation,"  u.  s.  w.     Wien,  1843. 
Valentine,  G.     "  De  functionbus  nervorum  cerebralium  et  nervi  sympatheti."     Berne, 

1839. 
Van  der  Kolk,  J.  L.  C.      "  Spinal  Cord  and  Medulla  in  Epilepsy."      New  Sydenham 

Soc, 1859. 
"  Cerebral  Atrophy."     New  S3''denham  Soc,  1861. 
ViRCHOW,  R.     "  Das  Hi^matora  der  Dura  Mater."     Verhandl.  d.  phys.  med.  Gesell.  in 

Wiirzb,  1857. 
VoN  DuscH.     "  On  Thrombosis  of  the  Cerebral  Sinuses."     London,  1861. 
VoN  Ziemssen,  H.     "  Chorea."     Ziemssen,  vol.  xiv. 
Voulet.     "  De  la  contraction  hysterique  permanente."     Paris,  1872. 
Wadsworth,  0.  F.     "  Three  Cases  of  Homonymous  Hemianopsia."      Boston   Med.   and 

Surg.  Jour.,  May,  1884.   ' 
Walton,  G.  L.     Article  on  "Hysteria."     Ref  Hand-book  Med.  Sci. 

"  Neglect  of  Ear  Symptoms  in  the  Diagnosis  of  Diseases  of  the  Nervous  System." 

Jour,  of  Nerv"  and  Ment.  Dis.,  1882. 
Webber,  S.  G.     "  Diseases  of  Peripheral  Cerebro-Spinal  Nerves."     Ziemssen's  Supplement. 

"Treatise  on  Nervous  Disease."     New  York,  1886. 
Wernicke,  C.     "  Lehrbuch  der  Gehirnkrankheiten."     Berlin,  1883. 
Westphal,  C.     "A  Contribution  to  the  Study  of  Syringomyelia  (Hydromyelia)."     Brain, 

July,  1883. 
"  Ueber  einen  Fall  Hohlen  und  Geschwulstbildung  in  Riickenmarke  mit  Erkran- 

kung  des  verlangerten  Marks  und  einzelner  Hirnnerven."     Arch,  f  Psych. 

und  Nervenkr.,  1875. 
Whatton,  W.  R.     "Spinal  and  Spino-Ganglial  Irritation."     North  of  England  Med.  and 

Surg.  Jour.,  1831. 
Whittaker,  J.  F.     Article  on  "Cerebro-Spinal  Meningitis."     Ref  Hand-book  Med.  Sci. 
WiLDBRAND,  H.     "  Ueber  Hemianopsie  und  ihr  Verhaltniss  zur  topischen  Diagnose  der 

Gehirnkrankheiten."     Berlin,  1881. 
"  Ophthalmiatrische    BeitrJige  zur  Diagnostik  der  Gehirnkrankheiten."      Wies- 
baden, 1884. 
WiLKS,  S.     "  Lectures  on  Diseases  of  the  Nervous  System."     London,  1878. 
Wilson,  J.  C.     "  Alcoholism."     Pepper's  Syst.  Pract.  Med. 
Wolf.     "  Monomania."     Med.  Record. 
Wood,  H.  C.     Articles  on  "  Neurasthenia"  and  "  Syph.  Dis.  of  Nerve  Centres."      Pepper's 

Syst.  of  Pract.  Med. 
"Nervous  Diseases  and  their  Diagnosis."     Philadelphia,  1886. 
Wright,  H.  G.     "  Headaches  :  their  Cause  and  their  Cure."     London,  1865. 
Zenner,  p.      Articles  on    "Hemiplegia"    and   "Corpus    Striatum."      Ref    Hand-hook 

Med.  Sci. 
Zimmerlin,    Franz.       "  Ueber    hereditiire     (familiare)    progressiven    Muskelatrophie." 

Zeitschr.  f  kl.  Med.,  vii. 
Zunker.     "  Beitrage  zur  Myelitis  Chronica."     Charite  Annalen,  v,  1880. 


INDEX. 


Abdominal  reflex,  96 

Abolition  of  reflexes,  352. 

Acute  ascending  spinal  paralysis,  442-444 

diagnosis  of,  443 

etiology  of,  442 

morbid  anatomy  of,  442 

prognosis  of,  444 

symptoms  of,  442,  443 

treatment  of,  444 
Adams'  frictional  machine,  649 
-Esthesiometers,  200,  201 
^Esthesodic  system  of  spinal  cord,  91 
Age  of  patients,  its  clinical  relations.  111 
Ages,   relative,   nervous   diseases  common 

to.  111 
Ageusia,  210 

Agglomerate  Leclanche  cell,  623 
Agraphia,  64,  234,  236 
Albuminuria,  from  medullary  lesion,  78 
Alcoholic  poisoning,  572-578 
Alcoholism,  acute.  572,  573 

chronic,  574-576 

prognosis  of,  576,  577 
symptoms  of,  573,  576 
treatment  of,  577,  578 
Alexia,  234 
Amaurosis,  208 
Amblyopia,  208 
Amimia,  234 
Amp§re,  618 
Amyotrophic  lateral  sclerosis,  376-379 

diagnosis  of,  378 

deformity  of,  377 

etiology  of,  376 

morbid  anatomj'-  of,  376 

prognosis  of,  379 

stages  of,  377,  378 

symptoms  of,  377,  378 
table  of,  422 

treatment  of,  379 
Anfemia,  cerebral,  electricity  in,  714,  715 
Anaesthesia,  202,  203 

alcoholic,  575 

diagnostic  importance  of,  203 

electricity  in,  725 

from  lead,  569 
Anarthria,  76 

Anelectrotonic  action  of  electricity,  687 
Angioneuroses  of  the  skin,  729 
Ankle-jerk,  tests  for,  173 
Anode,  608 

efi"ect  of,  638 
Anosmia,  79,  208 


Anterior  spinal  sclerosis,  357 
Ape-hand,  381 
Aphasia,  233-239 

amnesic,  60,  63 

ataxic,  16,  60,  61 

clinical  deductions  respecting,  66-68 

coexisting  with  hemianopsia,  82 

diagram  of,  67 

differential  diagnosis  of,  66,  238,  239 

etiology  of,  66,  233,  234 

from  lesions  of  internal  capsule,  30 

its  clinical  signiticance,  60-67 

morbid  anatomy  of,  66,  233,  234 

motor,  63,  233,  234 

prognosis  of,  239 

symptoms  of,  66,  234—236 

treatment  of,  239 
Apoplectic  coma,  262,  263 

foci,  260 

stroke,  262 
Apoplexy  (see  cerebral  hemorrhage) 
Application  of  static  electricity,   methods 

of,  665-675 
Apraxia,  234 
Aqueduct  of  Sylvius,  31 
Arachnitis,  293 

Architecture  of  brain  and  spinal  cord,  dia- 
grammatic summary  of,  97-103 
Arcus  senilis,  121 

Argyll  Robertson's  pupil,  93,  400,  401 
Armstrong's  frictional  machine,  650 
Arsenical  paralysis,  571,  572 
Arteritis  obliterans,  77 
Asthenopia,  130,  131,  528 
Asthma,  spasmodic,  electricity  in,  723 
Astigmatism,  129,  130 
Asymbolia,  234 
Ataxia,  cerebellar,  404 

cerebral,  81,  332,  404 

from  brain-lesions,  276 

generic,  591 

hereditary,  591 

hysterical,  404 

of  spinal  origin,  93 

spinal,  404 
Atheroma,  221,  222,  223 

etiology  of,  222 

morbid  anatomy  of,  221 

symptoms  of,  222 
Athetosis,  161 

symptoms  of,  table  of,  498 
Atrophic  spinal  paralysis,  365 
Atrophy  of  brain,  335 

(763) 


764 


INDEX 


Atrophy  of  muscles,  a  symptom  of  spinal 
disease,  352 

of  optic  nerve  in  locomotor  ataxia,  401 
Atropia  in  eye-examinations,  necessity  of, 

146 
Attachments  to  a  complete  battery,  627-639 
Attitude,  a  euide  in  diagnosis,  162-167 

caused  by  cerebellar  disease,  76 
Auditory  tracts,  42 

of  brain,  30 
Aurae  of  epilepsy,  476 

of  petit  mal,  478 

Bailey's  fluid  rheostat,  632 
Basedow's   disease,  598 
Battery,  care  of,  645,  646 

choice  of,  639,  640 

complete  attacliments  to,  627,  639 

desirable  points  in,  639,  640 

fluid,  renewal  of,  645 

permanent,  643,  645 
Battery  current  (see  galvanic  current) 
Beard  and  Rockwell's  method,  690 
Bed-sores,  after  cerebral  hemorrhage,  277 
Bell's  palsy,  123 

paralysis,  85,  152 
Benedict's  method,  690 
Bladder  and  rectum,  affections  of,  in  loco- 
motor ataxia,  400,  401 
Bladder,  paresis  of,  403 
Blepharospasm,  electricity  in,  723 
Boat-shaped  abdomen,  307 
Boulimia,  509 

Boze's  frictional  machine,  648 
Brachialgia,  508 
Brach-Romberg  sj-mptom,  403 
Brain,  abscess  of  (see  cerebral  abscess) 

a  composite  organ,  2 

architecture  of,  diagram  of,  34 

atrophy  of  (see  cerebral  atrophy) 

base  of,  diagram  of,  74 

cells  of,  6-8 

congenital  defects  of  217-219 

diagram  of  transv^erse  antero-posterior 
section  of,  24 

embolism  of,  229-233 

fatty  tumors  of,  340 

fibrous  tumors  of  340 

fluxionary,  hyperasrnia  of  241 

general  physiology  of,  2-10 

hydatids  of,  340 

hyperemia  of,  239-249 

hypertrophy   of  (see   cerebral   hyper- 
trophy) 

induration  of  329,  330 

inflammatory  diseases  of  218 

injuries  of  eff'ects  of,  2,  3 

lesions  of,  effects  of,  diagram  of  255 

lesions  of,  general  s3'mptomatology  of, 
264 

motor  tracts  of,  diagram  of,  258 

osseous  tumors  of,  340 


Brain,  parasitic  tumors  of,  340,  341 

pearl-tumors  of,  340 

sand-tumors  of  340 

sclerosis  of  (see  cerebral  sclerosis) 

sensory  tracts  of  diagram  of  259 

softening  of  (see  cerebral  softening) 

structural  diseases  of,  218 

thrombosis  of  vessels  of,  223-225 

tumors  of,  218  (see  also  cerebral  tumors) 
etiology  of  341 

vascular  tumors  of,  340. 

vessels  of  diseased  conditions  of,  217 
Breeze,  static,  670-672 
Broca's  centre,  60 

of  speech,  15,  16 
Bromism,  579-581 

symptoms  of,  580,  581. 

treatment  of,  581 
Bulbar  paralysis,  378 

from  lesions  of  the  internal  capsule,  30 
Bulbar  symptoms,  with  cerebellar  disease, 

787. 
Bunsen's  cell,  627 

Cabinet  battery,  advantages  of,  641 

description  of  641 
Cachexia,  120,  121 
from  lead,  568 
Cachexic  pachydermique,  601 
Calorimeter,     differential,    thermo-electric, 

632,  633 
Cancer  of  brain,  339 
Capsule,  external,  fibres  of  28 
lesions  of,  72,  73 
of  cerebrum,  31 
internal,  67  (see  also  internal  capsule) 
caudo-lenticular  portion  of  29 
effects  of  brain  lesions  of,  30 
fibres  of  28 
knee  of,  29 
lesions  of,  73 

of  brain,  subdivisions  of,  29,  30 
of  cerebrum,  course  of,  30 
thalamo-lenticular  portion  of,  29 
Carcinomata  of  brain,  339 
Cardialgia,  508 
Care  of  a  battery,  645,  646 

of  an  induction  machine,  661-665 
Case-book,  sample  page  of,  116 
Case,  crowbar,  2 
Catalepsj',  514,  515 

facial  expression  of,  155,  156 
Catalytic  action  of  electrical  currents,  688, 

689 
Catelectrotonic  action  of  electricity,  686 
Cathode,  608 

effect  of  638 
Cautery  battery,  608,  698 
Cell  of  cerebral  cortex,  diagram  of,  7 
Cells  of  brain,  6-8 
Central  galvanization,  691 
Central  myelitis,  407-409 


I 


f 


INDEX. 


765 


Central  myelitis,  diagnosis  of,  408 
etiology  of,  407 
morbid  anatomy  of,  407 
prognosis  of,  408 
symptoms  of,  407,  408 
treatment  of,  408 
Centres  of  optic  thalamus,  24-26 
Centres  of  speech,  G6-68 
Cephalgia,  508 
Cerebellar  cortex,  39 
disease,  gait  of,  165 
hemorrhage,  76 
nuclei,  39 
Cerebellum,  architecture  of,  37 

architecture  of,  diagram  of,  38 
diagrammatic  summary  of,  99 
effects  of  lesions  of,  39-41,  76,  77 
fibres  of,  99 
functions  of,  16,  39-41 
inferior  peduncle  of,  37 
its  control  over  equilibrium,  35 
middle  crura  of,  symptoms  due  to,  77 
middle  peduncles  of  34,  37 
nerves  connected  with,  39 
peduncles  of  37 
superior  peduncle  of,  31,  32,  38 
Cerebral  abscess,  diagnostic  symptoms  of, 
table  of,  328,  329 

differential  diagnosis  of,  326-329 

etiology  of,  327 

morbid  anatomj'  of,  326,  327 

prognosis  of,  329 

symptoms  of  327,  345 

treatment  of  329 

varieties  of,  326 
affections,  electricity  in,  712-716 
anaemia,  differential  diagnosis  of,  252, 
253 

electricity  in,  714,  715 

etiology  of,  250,  251 

morbid  anatomy  of,  249,  250 

prognosis  of,  253 

symptoms  of,  251,  252,  345 

treatment  of  253,  254 
apoplexy  (see  cerebral  hemorrhage) 

symptoms  of,  345 
table  of  480 
architecture,  diagram  of,  5 

methods  of  study  of,  11,  12 
ataxia,  276,  404 
atrophy,  335 

differential  diagnosis  of,  336 

etiology  of  335,  336 

morbid  anatomy  of,  335 

prognosis  of,  336 

symiitoms  of  336 

treatment  of  336 

varieties  of  335,  336 
automatism,   as    shown    in    the    frog, 

4,  5 
congestion,  241 

symptoms  of  table  of,  480 


Cerebral  cortex,  destructive  lesions  of,  effects 
of,  49 
functions  of,  8,  9 
irritative  lesions  of,  effects  of,  49 

depression,  243,  244 

diseases,  advent  of,  345 
convulsions  in,  345 
coma  in,  345 
cranial  pain  in,  345 
defects  in  speech  in,  345 
disturbance  of  special  senses  in,  345 
electro-contractility  in,  345 
impairment  of  intellect  in,  345 
motor  paralysis  in,  345 
muscular  contracture  in,  345 
sensory  paralysis  in,  345 
summary  of,  symptoms  of,  345 
symptoms  of  diagnostic  value  of, 

table  of,  345 
tremor  in,  345 

embolism,  227,  229-233 

differential  diagnosis  of,  232,  233 
etiology  of,  230,  231 
morbid  anatomy  of,  229,  230 
])rognosis  of,  233 
symptoms  of,  231,  232,  345 
treatment  of,  233 

fluxion,  241 

glioma,  illustration  of,  339 

hsematoma  (see  pachymeningitis) 

hemiplegia,  285,  286 

hemispheres,  97,  98,  183-185 

hemorrhage,  254 

differential  diagnosis  of,  278,  279 
etiology  of,  260,  261 
morbid  anatomy  of  254-260 
symptoms  of,  261-279 
treatment  of,  279-281 

hypersemia,  239-249 

differential  diagnosis  of,  246 
electricity  in,  713,  714 
etiology  of,  240-243 
morbid  anatomy  of  240 
symptoms  of,  243-245,  345 
treatment  of  246-249,  713 
varieties  of,  239-241 

irritation,  243,  244,  306,  307 

localization,  views  respecting  it,  2 

meningeal  hemorrhage,  282 

meningitis,  acute,  293 

differential  diagnosis  of,  296 
diffuse  variety  of,  293 
etiology  of  294 
morbid  anatomy  of,  293 
prognosis  of  297 
symptoms  of,  294,  345 
synonvms  for,  293 
treatment  of,  297,  298 

sclerosis,  329 

differential  diagnosis  of,  333,  334 
etiology  of  330 
illustration  of,  332 


766 


INDEX. 


Cerebral  sclerosis,  morbid  anatomy  of,  329, 
330 
prognosis  of,  334 
symptoms  of,  330,  331,  345 
treatment  of,  334,  335 
varieties  of,  329,  330 
softening,  317 

diagnostic  symptoms  of,  table  of, 

3i'8,  329 
differential  diagnosis  of,  322-324 
etiology  of,  318 
morbid  anatomy  of,  317 
prognosis  of,  325 
symptoms  of,  319,  345 
treatment  of,  324-326 
varieties  of,  317,  318 
thermometry,  211,  212 

studv  of,  633 
thrombosis,  223-225 

capillary  variety,  etiology  of,  228 
morbid  anatomy  of,  228 
symptoms  of,  228,  229 
differential  diagnosis  of,  226,  227 

table  of,  227 
etiology  of,  223 
morbid  anatomy  of,  223 
■  prognosis  of,  228 
svmptoms  of,  223-225,  345 
treatment  of,  228 
tumors,  218,  337 

diagnostic  symptoms  of,  table  of, 

328,  329 
differential  diagnosis  of,  343 

from  cerebral  softening,  323, 
324 
etiology  of  341 
morbid  anatomy  of,  338,  339 
prognosis  of,  343 
symptoms  of,  341,  342,  345 
treatment  of,  343,  344 
varieties  of,  218,  337-339 
Cerebro-spinal  axis,  fibres  of,  diagram  of,  34 
Cerebro-spinal  sclerosis,  svmptoms  of,  table 

of,  498 
Cerebrum,  capsular  fibres  of,  28,  98 
caudate  nucleus  of,  20 
circulation  of,  diagram  of,  242 
convolutions  of,  diagram  of,  12 
corpus  striatum  of,  16,  20 
cortex  of,  13,  14 

destructive  lesions  of,  285 
irritative  lesions  of,  285 
cortical  areas  of  diagram  of,  14 
cortical  centres  of,  11 

diagram  of,  10 
cortical  lesions  of,  69-71 

symptoms  of,  266,  267 
diagram  of  transverse  antero-posterior 

section  of,  24 
effects  of  cortical  lesions  of,  49,  50 
effects  of  removal  of,  4,  5 
fibres  of,  17-19 


Cerebrum,  fissures  of,  13 

ganglia  at  base  of,  20 

geniculate  bodies  of,  20 

inflammation  of  (see  encephalitis) 

internal  capsule  of,  diagram  of,  255,  268 

lenticular  nucleus  of,  20 

lesions  at  base  of,  82 

lobes  of,  13 

motor  centres  of,  diagram  of,  54 

motor  centres  of  (Horsley),  49-51 

muscular  area  of,  14 

non-cortical  lesions  of,  72 
symptoms  of,  26?,  268 

obscure  lesions  of,  tests  used  in  diag- 
nosis of,  183-185 

optic  thalamus  of,  16,  20 

sight  area  of,  in  occipital  lobe,  15 

speech  area  of,  15,  16 

temporal    cortex    of,   its    relation    to 
hearing,  15 
Cervical  paraplegia,  177 

sympathetic,  diseases  of,  electricity  in, 
728,  729 

irritation  of,  728 

paralysis  of,  728 

Charcot's  disease,  401,  402 

illustrations  of,  399,  402 
Charging  of  a  static  machine,  664 
Cheirospasm,  436 

Childhood,  nervous  diseases  common  to.  111 
Choice  of   a  battery  and  electrical   appa- 
ratus, 639-645 
Choked  disk,  81,  208 

diagram  of,  322 

in  cerebral  tumors,  342 
Cholesteatomata,  340 
Chorea,  494-506 

complications  of,  497 

diagnosis  of,  497 

from  cerebral  sclerosis,  333 

etiology  of,  494,  495 

facial  expression  of,  155 

galvanism  in  722 

its  dependence  upon  anomalies  of  the 
visual  apparatus,  501-505 

morbid  anatomy  of,  495 

post-paralytic,  symptoms  of,  table  of, 
498 

prognosis  of,  497-500 

static  electricity  in,  722 

symptoms  of,  495,  496 
table  of  498 

treatment  of,  500-506 
Chronic  cerebral  meningitis,  299 

mj^elitis,  diagnosis  of,  405 
Cilio-spinal  centre,  415 
Cincture-feeling,  91,  93,  408 
Claustrum,  28 
Claw-hand,  381 

Clinical  history  of  patients,  108-116 
Column,  direct  cerebellar,  92 

of  spinal  cord,  37,  41 


INDEX. 


767 


Columns  of  Burdach,  88,  91 

of  Goll,  88,  91 

of  Tiirck,  88 

vesicular,  of  Clarke,  94 
Coma,  alcoholic,  278,  279 

apoplectic,  278 

causes  of,  differential  diagnosis  of,  table 
of,  480 

differential  diagnosis  of,  278,  279 

from  cerebral  embolism,  278 

from  chloral,  279 

from  opium,  279 

in  cerebral  lesions,  72 

i;ra3mic,  278 
Combined  current,  686 
Commutator,  636 

Complete  battery,  attachments  to,  627-639 
Conducting  tracts  of  spinal  cord,  87,  92 
Congenital  muscular  spasm,  440-442 
Conjugate  deviation  of  eyes  and  head  from 

cerebral  hemorrhage,  274,  275 
Consciousness,  in  connection  with  cortical 

lesions,  69 
Constant  current  (see  galvanic  current) 
Contracture,  a  symptom  of  s]nnal  disease,  96 

of  muscles,"  276,  277,  345,  352 
from  spinal  disease,  94,  96 

post-paralytic,  166,  167 
Convulsions,  alcoholic,  575 

of  cortical  origin,  70 
Convulsive  tremor,  symptoms  of,  table  of, 

498 
Coordination,    tests    for   derangements   of, 

179-181 
Cornmg's  method,  690 
Corpora  quadrigemina,  effects  of  lesions  of, 
33 

their  relations  to  the  tegmentum  cruris, 
33 
Corpus  striatum,  16,  20 

fibres  of  diagram  of,  21 

functions  of  22 

two  nuclei  of  20 
Cortex  of  cerebrum,  diagram  of  areas  of,  14 

functions  of,  8,  9 
Cortical  area,  of  hearing,  15,  16 
of  speech,  15,  16 

areas,  functions  of,  13-16 

centres  of  cerebrum,  11 

paralysis,  49 

spasm,  49 
Coughing,  electricity  in,  724 
Coulumb,  617 
Cranial  pain,  69 

in  cerebral  lesions,  72 
Cremasteric  reflex,  96 
Cretinism,  156 
Crossed  facial  paralysis,  74,  75 

olfactory  paralysis,  80 

paralysis,  of  facial  nerve,  85 
of  motor  oculi  nerve,  82 
of  trigeminus  nerve,  84 


Crossed  paralysis,  with  involvement  of  optic 
nerve,  80,  81 

pyramidal  fibres,  distribution  of,  dia- 
gram of,  358 

trigeminal  paralysis,  75 
Cross-eye,  its  clinical  importance  contrasted 
with  insufficiency,  467.  468 

its  relation  to  refractive  errors,  453 
Crowbar  case,  2 
Crus  cerebri,  31 

diagram  of  a  cross-section  of,  32 

its  relation  to  third  cranial  nerve,  31 

lesions  of,  73,  74 

speech  tract  in,  67 
Crusta  cruris,  31 
Cuneus,  effects  of  lesions  of,  70,  71 

lesions  of,  81 
Current-selector,  634,  636 
Cutaneous  vessels,  paralysis  of,  729 
Cycloceyihalous  deformity,  219 
Cysts  of  brain,  339 

Darnell's  cell,  625 

Deflection  of  head  and   eyes  in  cerebellar 

Delayed  sensation,  91,  206,  398 
Delirium  tremens,  572 
Dementia,  paralytic,  152 
Dental  irritation  in  epilepsy,  464 
Detection  of  buried  metal,  196 
Diabetes,  from  medullary  lesion,  78 
Diagnostic  key-board,  192 
Diatheses,  112,  113,  119,  120 

gouty,  119 

lymphatic,  120 

nervous,  119 

strumous,  119 
Differential     calorimeter,     thermo-electric, 

632,  633 
Diplopia,  a  clinical  evidence  of  strabismus. 

461 
Direct  cerebellar  tracts,  42 

spark,  667,  668 
Duchenne's  disease,  78,  85,  86,  151, 152,  378 

electricity  in,  716 

facial  expression  of  384,  385 
Dura  mater,   inflammation  of  (see  pachy- 
meningitis) , 
Duration  of  symptoms,  clinical  significance 

of,  110 
Dynamograph,  178 
Dys|)hagia,  86 
Dysphysia,  78 

Ear,  a  guide  in  diagnosis,  154,  155 
Electric  currents,  varieties  of  608-613 
Electrical  apjiaratus,  choice  of  639-645 
Electrical  bath,  691,  692 

currents,  theraneutical  action  of.  655, 
656 

reactions  of  muscles,  186-189 

tests  of  the  skin,  198,  199 


768 


INDEX. 


Electrical  tosts,  table  of  record  of  191 

units,  table  of,  617 
Electricity,  in  anajstliesia,  725 

in  cerebral  affections,  712-716 

in  diseases  of  the  cervical  sympathetic, 
the  vaso-motor  system,  and  allied 
neuroses,  728,  729 

in  disorders  affecting  sensory  nerve- 
tracts,  724-728 

in  facial  spasm,  722,  723 

in  liemianEesthesia,  726 

in  inflammatory  diseases  of  the  cord, 
719 

in  neuralgia,  726,  727 

in  nystagmus,  723 

in  paralysis,  719,  720 

in  paresis,  719,  720 

in  sneezing,  coughing,  and  hiccough, 
721 

in  spasmodic  affections,  720 

in  spasmodic  asthma,  723 

in  spinal  affections,  717 

in  tetanus,  724 

in  torticollis,  723 

in  trophic  disorders,  726 

in  wry-neck,  723 
Electrization  of  the  spinal  cord,  717-719 
Electrodes,  636-639 

flat,  637 

placing  of,  680 

pressure  on,  681 

saturation  of,  680,  681 

size  of,  measurement  of,  679 

small  tip,  637 

sponge,  reasons  for  removal  of  sponges, 
639 

wire  brush,  637 
Electro-diagnosis,  of  aural  diseases,  196, 197 

general  principles  of  1»5-187 
Electrolysis,  608,  693-697 

effects  of  positive  and  negative  pole  in, 
693 

general  rules  for,  696,  697 

in  aneurism,  695 

in  cancer,  696 

in  extra-uterine  pregnancy,  696 

in  goitre  and  Basedow's  disease,  696 

in  hydrocele,  696 

in  urethral  stricture,  695,  696 

needles  for,  693,  694 
Electro-piiysios,  606-675 
Electro-therapeutics,  675-729 

general  rules  for,  699-703 

statical,  702-711 
Embolism,  227,  229-233 
Encephalitis,  316 

differential  diagnosis  of,  317 

etiology  of,  316 

morbid  anatomy  of,  316 

symptoms  of  317 
Encephalocele,  219 
Encejihaloid  tumors  of  brain,  339 


Endarteritis  obliterans,  224 
Ejiigastric  reflex,  96 
Epilepsy,  472-483 

complications  of,  479,  481 

conditions  of  visual  apjiaratus  in,  474 

diagnosis  of,  476,  477,  479 

electricity  in,  722 

etiology  of,  472-474 

eye-defects  in,  table  of,  489 

facial  expression  of,  155 

irregular,  479 

morbid  anatomy  of,  475 

ocular  defects  in,  722 

prognosis  of,  481,  482 

symi)toms  of,  475-478 
table  of  480 

treatment  of,  482-494 

varieties  of  472 
Epileptic  auraj,  476 

cry,  476 

seizure,  477,  478 
Epileptiform  attacks,  86 
Ejiithelial  tumors  of  brain,  339 
Esophoria,  143 
Exaggerated  reflexes,  352 
Examination  of  patients,  necessity  for  care 

m,  107,  108 
Exophoria,  143 
Exophthalmic  goitre,  598-601 

diagnosis  of,  600 

etiology  of,  599 

morbid  anatomy  of,  598,  599 

prognosis  of  600 

symptoms  of,  599,  600 

treatment  of,  600,  601 
Experiments  relating  to  artificial  convulsive 

seizures,  463 
Extra-uterine   pregnancy,  electrical   treat- 
ment of,  696 
Eye,  abductive  power  of,  test  for,  139 

adductive  power  of,  test  for,  139 

a   factor   in  the   causation  of  nervous 
symptoms,  124-130 

a  guide  in  diagnosis,  133-150 

aslhenopic,  130,  131 

astigmatic,  129,  130 

changes  observed  in,  121-123 

clinical  alterations  in,  123-128 

degenerative  effects  of  extirpation  of, 
25. 

examination  of,  table  of  record  for,  145 

hypermetropic,  126-129 

in  cerebral  tumors,  342 

lids  of  a  guide  in  diagnosis,  151 

movements  of,  121 

muscles  of,   insufficiency   of,  .130-132, 
137,  138 

muscles  of  paresis  of  122 

muscular  anomalies  of,  new  terms  for 
(Stevens),  140-144 

muscular  anomalies  of,  tests  for,  137- 
150 


I 


I 


I 


I 


INDEX. 


7G9 


Eye,  myopic,  129 

neuro-retiuitis  of,  diagram  of,  322 
normal  fundus  of,  diagram  of,  322 
physiology  of  movements  of,  121,  122 
refractive  errors  of,  tests  for,  133-138 
sursumduction  of,  tests  for,  139 

Eyes,  conjugate  deviation  of,  75 

Face,  cortical  ai-ea  of,  50 

hemianaestliesia  of  83 
Facial  hemiatrophy,  386 

deformities  produced  b}',  386 
Facial  s|iasm,  153 

electricity  in,  722,  723 
Farad,  618 
Faradaic  current,  608-612 

catalytic  action  of,  689 

in  spinal  diseases,  718 

its  stimulating  effects,  685,  686 

modifying  effects  of,  686,  687 

table  of,  contrasted  with  galvanic  cur- 
rent, 616 
Fauces,  in  facial  paralysis,  85 
Features,  clinical  study  of,  117-119 
Feigned  disease,  detection  of,  195 
Fibres,  associating,  of  cerebrum,  17 

commissural,  of  cerebrum,  17 

of  cerebro-spinal  axis,  diagram  of,  34 

of  cerebrum,  classification  of,  17-19 
diagram  of,  18 

peduncular,  of  cerebrum,  17 

]\vramidal,  of  brain,  28-30,  36 
Fibrillary  twitchings,  383 
Fillet  (see  lemniscus-tract) 
Fissure  of  Rolando,  external  guides  to,  50, 
51 

of  Sylvius,  external  guides  to,  50,  51 
Fissures  of  cerebrum,  13 
Flechsig's  method,  19 
Fluid  rheostat  of  H.  L.  Bailey,  632 
Focal   lesions,    of  cervical    segments,  411, 
■412 

of  dorsal  segments,  411,  412 

of  lateral  half  of  spinal  cord,  414 

of  lumbar  segments,  412,  413 

of  spinal  cord,  408-448 
Foot-clonus,  96 

its  clinical  significance,  174 

tests  for,  173 
Foot-reflex,  96 

Forehead,  clinical  facts  relating  to,  120, 121 
Formatio  reticularis,  43,  45 

its  relation  to  sensory  tracts,  84 
Formication,  55,  56 
Fornix,  fibres  of,  17 

pillars  of,  28 
Frictional  machine,  of  Adams,  649 

of  Armstrong,  650 

of  Holtz,  650 

of  Lane,  649 

of  Nicholson,  649 

of  Otto  V.  Guericke,  647 


Frictional  machine,  of  Professor  Boze,  648 
of  Toepler,  650 
of  Voss,  650 
Friedreich's  disease,  591 
Front-tap  contraction,  173 
Fuller's  cell,  624 

Functional  nervous  diseases,  as  purely  re- 
flex manifestations,  4().!-472 
necessity    for    examination    of    reflex 

causes  of,  470,  471 
their  relationship  to  anomalies  of  the 
visual   apparatus   and  other   rellex 
causes,  452-472 
views  respecting  medication  in,  471 
Functional  parajdegia,  435,  43G 
etiology  of,  435 
symptoms  of,  435,  436 
treatment  of,  436 

Gait,  a  guide  in  diagnosis,  162-165 

of  cerebellar  disease,  76 
Galvanic  batteries,  tnetiiods  of  construi^t- 

ing,  619,  623 
Galvanic  battery,  key-board  attachments, 
640 

method  of  connecting  the  cells,  effect 
on  intensity,  619-621 
Galvanic  cell,  613-623 

electro-motive  force  of,  676 

external  resistance  of,  615,  616 

internal  resistance  of,  615 

one-fluid  cells,  with  liquid  depolarizers 
623,  624 

one-fluid  cells,  with  no  depolarizer,  62o 
with  solid  depolarizers,  623 

resistan<«  of,  615 

simplest  form  of,  614,  615 

special  forms  of,  623-627 

varieties  of,  618 
Galvanic  current,  608 

catalytic  action  of,  688,  689 

density  of,  679 

in  spinal  diseases,  717,  718 

length  of  application  of,  683 

modifications  oC  60S 

modifying  effects  of,  687 

quantity  of,  676 

table  01,  contrasted  with  galvanic  cur- 
rent, 616 
Galvanic  dosage,  675-684 
Galvanic  formulfB  of  muscles,  186,  187 
Galvanic  measurement,  675-684 
Galvanism,  in  chorea,  722 

its  effects  on  living  tissues,  684 

its  sedative  action,  684 

its  stimulating  effects,  684,  685 

its  various  properties,  684,  685 
Galvanization  of  the  cervical  sympathetic, 

689,  690 
Galvano-cautery,  697-699 
Galvanometer,  627,  628 
Ganglia,  basal,  98 


49 


770 


INDEX. 


Gastric  crises,  in  cerebellar  disease,  7G 

Gastro-enteritis,  310 

General  electro-therapentics,  684-702 

General  faradization,  690 

General  galvanization,  691 

General  paralysis,  336 

Generic  ataxia,  591 

Girdle  pain,  91,  93 

Girdle  sensation,  91,  93,  408 

Glioma  of  brain,  339 

illustration  of,  339 
Globus  hystericus,  508 
Goitre,  exoj>htlialmic,  598 
Grand  nial,  476-480 
Graphospasm,  436 
Graves'  disease,  598 

Gravity -cell  battery,  advantages  of,  641 
Gray  degeneration  of  spinal  cord  (see  loco- 
motor ataxia) 
Grenet  cell,  624,  645 
Grove's  cell,  626 
Gubler's  line,  36,  74,  85 
Gudden's  method,  19 

Guericke,  Otto  v.,  frictional  machine  of,  647 
Guides  to  focal  spinal  lesions,  410-415 
Gummata  of  brain,  338 
Gums,  a  guide  in  diagnosis,  153 

Haematoma  of  the  dura  mater  (see  pachy- 
meningitis) 
Hssmatomyelia,  425-427 
llcematorrhachis,  427,  428 
Hair,  changes  in,  after  paralysis,  277 
Hallucinations,  from  lesions  of  the  thala- 
mus, 25,  27 
Hand,  a  guide  in  diagnosis,  156-162 

atrophy  of,  157 

bird-claw,  169,  170 

deformities  of,  encountered,  156 

in  progressive  muscular  atrophy,  381, 
382 

of  the  idiot  and  imbeciles,  161 

tremor  of,  156 

woolly,  161 
Head,  abnormal  posture  of,  from  eye-defect, 

121-123 
Hearing,  disturbances  of,  "with  facial  paral- 
ysis, 85 

tests  of,  210 
Hearing  imjiressions,  cortical  area  of,  15 
Heart,  symptoms  referable  to  when  medulla 

is  implicated,  77,  78 
Hemianaesthesia,  55 

cerebral,  81 

electricity  in,  715,  726 

from  lesion  of  internal  capsule,  30 

in  connection  witli  hemianopsia,  81 

of  cortical  origin,  69 
Hemianopsia,  binasal,  58 

bitemporal,  58 

clinical  significance  of,  80,  81 

coexisting  with  motor  aphasia,  82 


Hemianopsia,  diagram  of,  57 
homonymous,  56,  185 

uncomplicated,     clinical     signifi- 
cance of,  81 
its  clinical  significance  and  varieties, 

56-58 
tests  for  detection  of,  56 
Hemiathetosis,  28 

Hemiatrophy,  of  face,  illustration  of,  386 
of  tongue  and  palate,  illustration  of, 
386 
Hemichorea,  28 
Hemiparaplegia,  353,  415 
Hemiplegia,  72,  86,  176,  353 

from  lesions  of  corpus  striatum,  22 

gait  of,  162 

its  clinical  significance,  52,  53 

of  cerebral  origin,  265,  266,  285,  286 

electrical  treatment  in,  715 
of  spinal  origin,  285,  286,  414 
Hereditary  ataxia,  591 
Heredity,  its  clinical  relation,  112 
Hiccough,  electricity  in,  724 
Hill's  gravity  cell,  625,  626 
Holtz  machine,  650,  653 

Ranney's  improvement  on,  657-661 
Hydrargysm,  diagnosis  of  579 
symptoms  of,  578,  579 
treatment  of,  579 
Hydrocefihalic  cr}^  307 
Hydrocephalus,  acute,  303 

attitude  of  patient,  166 
differential  diagnosis  of,  309 
etiology  of,  305,  306 
morbid  anatomy  of,  304 
prognosis  of,  310 
symptoms  of  306-308 
treatment  of,  311,  312 
acute  and  chronic,  symptoms  of,  345 
chronic,  312 

deformity  of,  314 
differential  diagnosis  of,  315 
etiology  of,  313,  314 
morbid  anatomy  of,  312 
prognosis  of,  315 
symptoms  of  314 
treatment  of,  315 
spurious,  310 
Hydromyelia,  433,  434 
Hydrophobia,  557-561 
diagnosis  of,  559 
etiology  of,  557 
morbid  anatomy  of,  557 
prognosis  of,  560 
symptoms  of,  558,  559 
treatment  of,  560 
Hydruria,  86 
Hyperemia,    cerebral,    electricity   in,   713, 

714 
Hyperesthesia,  56,  202,  203 

diagnostic  importance  of,  204,  205 
from  lead,  569 


INDEX. 


771 


Hyperesophoria,  143 

Hyperexophoria,  143 

Hyperkinesis,  720 

Hypermetropia,  126-129 

Hyperopia,   latent,   its    effect  on   nervous 

centres,  467 
Hyperosmia,  208 
Hyperphoria,  143 
Hypertrophy  of  brain,  337 

differential  diagnosis  of,  337 

etiology  of,  337 

morbid  anatomy  of,  337 

prognosis  of,  337 

symptoms  of,  337 
Hypoglossal  tract  of  brain,  29,  30,  36 
Hysteria,  506-519 

diagnosis  of,  510 

etiology  of,  507 

morbid  anatomy  of,  508 

symptoms  of,  508,  509 
table  of,  480,  498 

treatment  of,  515-519 
Hysterical  paralysis,  gait  of,  165 
Hystero-epilepsy,  511 

symptoms  of,  513 

Incontinence,     of     urine,     treatment      of, 
406 

paralytic,  175 

spasmodic,  175 
Incoordination  of  movements,  93 
Indirect  spark,  665-667 

length  of,  666 

volume  of,  667  . 

Induced  current  (see  faradaic  current) 

static,  672-675 
Induction  machine,  care  of,  661-665 
Infantile  ])aralysis,  365 

remittent  fever,  310 

spinal  paralysis,  369,  375 
Infarction,  229,  230 

Inflammatory   disorders  of  the  cord,  elec- 
tricity in,  719 
Injuries  of  brain,  effects  of,  2,  3 
Insufficiencies  of  eye-muscles,  general  rules 

for  determination  of,  454-456 
Insufficiency,   latent,  of  eye-muscles,  130- 
132,  137,  138 

of  ocular  muscles,  clinical  importance, 
467,  468 

of  the  eye-muscles,  manifest  and  latent, 
454 
Insula,  lesions  of,  71 
Insulation,  static.  670 
Intermittent  cramp  (see  tetany) 

tetanus,  437  (see  tetany) 
Internal  capsule,  diagram  of,  255,  268 

of  brain  (see  capsule,  internal) 

subdivisions  of,  268-270 
Interrupted  current  (see  faradaic  current) 
Interrupter,  of  faradaic  machine,  609 
Intra-cerebral  hemorrhage,  256,  257 


Island  of  Reil,  its  relation  to  speech,  16 
lesions  of,  71 

Jacksonion  epilepsy,  table  of  svmjjtoms  of, 

2S5 
Joints,  changes  in,  after  paralysis,  277 
Joule,  618 
Jouuod's  boot,  375 

Key-board  attachments,  of  galvanic  battery, 

640 
Kinesodic  system  of  spinal  cord,  93,  94 
Knee-jerk,  96 

abolition  of,  403 

tests  for,  173 
Kussmaul's  paralysis,  442 

Landry's  paralysis,  442 
Lane's  frictional  machine,  649 
Latent  insufficiency   of    eye-muscles,    132, 
137,  138 
muscular  anomalies  in  the  orbit,  456, 
457 
Lateral  spinal  sclerosis,  357 

diagnostic  table  of,  364 
diagram  of,  362 
etiology  of,  359 
morbid  anatomy  of,  359 
varieties  of,  359 
secondary  variety,  361 
diagnosis  of,  363,  364 
etiology  of,  361,  3()2 
morbid  anatomy  of,  361,  362 
prognosis  of,  365 
symptoms  of,  362-364 
treatment  of,  365 
Law,  of  Ohm,  618 
Lead-colic,  568 
Lead-encephalopathy,  569 
Lead-paralysis,  160,  568 
Lead-poisoning  (see  plumbism) 
Leclanche's  cell,  623 

agglomerate,  623 
Le  Fort's  method,  693 
Lemniscus  tract,  43,  46 
its  spinal  origin,  33 
its  two  bundles,  32,  33 
lesions  of,  77 
Leptomeningitis,  infantum,  303 

spinalis,  415-423 
Leyden-jar  spark,  668,  669 
Limbs,  cortical  areas  of,  50 
Line  of  Gubler,  36,  74,  85 
Lips,  a  guide  in  diagnosis,  151-154 
Living  tissues,  relative  resistance  of,  616 
Lobe,  occipital,  its  relation  to  sight,  15 
Localization,  cerebral,  views  respecting  it,  2 
Lock-jaw,  581 
Locomotor  ataxia,  390-405 
diagnosis  of,  404 
diagram  of  397 
etiology  of,  395,  396 


772 


INDEX. 


Locomotor  ataxia,  gait  of,  164,  388,  389 
gastric  crisis  in,  402,  403 
illustrations  of  clianges  in  cord  of,  302 
joint  changes  in,  3t)!)-401 
morbid  anatomy  of,  391-395 
pains  of,  397,  398 
prognosis  of,  405 
pupils  in,  396,  397 
stages  of,  390-398 
symptoms  of,  396-403 

relative  frequency  of,  403 
table  of,  549,  5G5 
treatment  of,  405,  406 
Lowenfeld's     deductions     relative    to    the 
action  of  galvanic  currents  on    the 
brain,  "715 
Lower  limb,  cortical  area  of,  50 
Jiungs,  symptoms   referable  to,  when   me- 
dulla is  implicated,  78 

Magneto-current,  613 
Marie-Davy  cell,  623 
Median  nerve,  paralysis  of,  158,  159 
Medulla,  injuries  of,  2 
oblongata,  100 

architecture  of,  diagram  of,  78 
component  parts  of,  41 
effects  of  lesions  of,  77,  78,  86 
functions  of,  16,  43-45 
nerves  of,  lesions  of,  85,  86 
nuclei  of,  diagrams  of,  42 
symptoms  of  compression  of,  86 
tracts  of,  diagram  of,  45 
vaso-motor  centres  of,  86 
Megalopsra,  123 
Megrim  (see  migraine) 

Memories,  affected  in  cortical  disease,  70-72 
of  nuiscular  acts,  cortical  centre  of,  16 
storage  of,  in  cerebral  cortex,  61,  62 
in  cortical  cells,  9 
Meningeal  hemorrhage,  282 

differential  diagnosis  of,  284 
etiology  of,  282 
morbid  anatomy  of,  282 
prognosis  of,  283 
symptoms  of,  283 
treatment  of,  283 
Meningitis,  basilar,  303 

cerebral,  chronic  varietj',  299 

differential  diagnosis  of,  301 
etiology  of,  300 
morbid  anatomy  of,  300 
prognosis  of,  3U2 
symptoms  of,  300,  301 
treatment  of,  302,  303 
subacute  variety,  298 

differential  diagnosis  of,  299 
etiology  of,  2i)9 
morbid  anatomy  of,.  299 
prognosis  of,  299 
symptoms  f)f.  299 
treatnieuL  of,  299 


Meningitis,  cerebro-spinal,  attitude  of  pa- 
tient, 1<56 
tubercular,  303  (see  hydrocej>halus) 
Mental  alcoholism,  576 

faculties,  pliysiology  of,  3,  13 
Mercurial  poisoning,  578,  579 
Mesencephalon,  99 
Method  of  Flechsig,  19 
of  Gudden,  19 
of  Tiirck,  19 
Meyer's  method,  680 
Microcejihalic  brain,  219 
Micropsia,  123 
Migraine,  532-541 

etiology  of,  532,  533 
heredity  of,  532,  533 
its  dependence  on  eye-strain,  532,  533 
symptoms  of,  533-539 
treatment  of,  539-541 
Miliary  aneurism,  220-222 
etiology  of,  221 
morbid  anatomy  of,  220 
symptoms  of,  221 
Milliampere-meter,  629-631,  677.  678 
Modifying    effects    of    electrical    currents, 

686-688 
Mogigraphia,  436 
Mono-ana3sthesia,  70 
Mono-para3sthesia,  70 
Monoplegia,  69,  70,  176,  264,  265 

electricity  in,  716 
Monospasm,  70 

electricity  in,  716 
Alorbid  fears,  529 
Morton's  pistol-electrode,  674 
Motor  impulses,  4 

paralysis,  rules  for  electrical  treatment 
in,  720  (see  paralysis) 
Mouth,  a  guide  in  diagnosis,  151-153 
Alovements,  rotary,  in  cerebellar  disease,  77 
Multiple  neuritis,  374,  561-567 
diagnosis  of,  564,  565 
etiology  of,  562 
morbid  anatomy  of,  561,  562 
prognosis  of,  566 
symptoms  of,  563,  564 

table  of,  565 
treatment  of,  566,  567 
sclerosis,  331 

spinal  sclerosis,  diagram  of,  363 
Aluscles,  electrical  reactions  of,  186-188 
Muscular  area  of  cerebrum,  14 

atropliy,  its  relation  to  spinal  diseases, 

93,  94 
reactions  to  galvanism,  normal,  190 
sense,  tests  of,  181,  182 
Myelitis,  428-433 
acute,  428 

diagnosis  of  430 

etiolog}^  of,  428 

morbid  anatomy  of,  428,  429 

prognosis  of,  430,  431 


I 


I 


INDEX. 


773 


Myelitis,  acnte,  symptoms  of,  429,  430 
treatment  of,  430,  431 
chronic,  431,  432 
diagnosis  of,  432 
etiology  of,  431 
morbid  anatomy  of,  431 
prognosis  of,  432 
symptoms  of,  431,  432 
treatment  of,  432 
diffuse,  symptoms  of,  table  of,  665 
symptoms  of,  table  of,  426 
Myelomeningitis,  429 
Myopia,  129 
Myosis,  403 

Myotonia  congenita,  440-442 
Myxoedema,  601-604 
diagnosis  of,  603 
etiology  of,  602 
morbid  anatomy  of,  601,  602 
prognosis  of,  604 
symptoms  of,  602,  603 
treatment  of,  604 

Nails,  changes  in,  after  paralysis,  277 
Nairne's   modification   of    Ramsden's    ma- 
chine, 648 
Nerve,  abducens,  lesions  of,  83 

facial,  course  of  fibres  of,  origin  of,  43 
decussation  of  its  fibres  within  the 

pons  varolii,  36 
effects  of  lesions  of,  85 
paralysis  of,  85 
motor  oculi,  lesions  of,  82 
paralysis  of  82 
special  nuclei  of,  82 
musculo-spiral,  paralysis  of,  159,  160 
olfactory,  lesions  of,  79,  80 
optic,  diagram  of,  57,  59 

lesions  of,  80-82 
trigeminus,  deep  fibres  of,  43,  44,  83 
general  clinical  deductions  relative 

to  lesions  of,  84 
paralysis  of,  83,  84 
trochlear,  lesions  of  83 
ulnar,  paralj'^sis  of  157,  158 
Nerve-reactions,  normal,  190 
Nerve-roots,  effects  of  lesions  of,  91 
spinal,  anterior,  93-95 
posterior,  91,  93,  95 
Nerve-stretching,  406 
Nerves  of  medulla,  lesions  of,  85,  86 
Nervous  bankruptcy,  466 

predisposition,  rationale  of,  468,  469 
Neuralgia,  541-553 
diagnosis  of  550 
differential  diagnosis  between  various 

types  of,  547 
electricity  in,  726,  727 
etiology  of,  542-544 
modifying  causes  of,  542 
morbid  anatomj'  of,  544—546 
predisposing  causes  of,  542 


Neuralgia,  prognosis  of,  550,  551 

symptoms  of  546-550 
tables  of,  547,  549 

treatment  of,  551-554 

trigeminal,  84 

types  of,  percentage  of,  545 

visceral,  electricity  in,  727 
Neurasthenia,  519-532 

cerebral,  525,  526 

diagnosis  of,  525 

etiology  of,  520-524 

morbid  anatomy  of  525 

prognosis  of,  529,  530 

spinal,  526,  527 

symptoms  of,  525-529 

treatment  of,  530-532 
Nicholson's  "  induction  machine,"  649 
Nuclei,  caudate  and  lenticular,  functions  of^ 
22 

of  the  medulla  oblongata,  42-45 
Nucleus,  caudate,  of  cerebrum,  20 

lenticular,  capsular  fibres  of,  28 
lesions  of,  73 
of  cerebrum,  20 

of  Stilling,  31 

red,  31,  32,  38,  39 

effects  of  lesions  of,  33 
Numbness,  55 
Nymphomania,  509 
Nystagmus,  76 

electricity  in,  723 

Ohm,  618 

Ohm's  law,  618,  683 
Omalgia,  508 

Ophthalmoplegia,  external,  82 
Ophthalmoscopic  examinations,  149,  150 
Ophthalmoscopy,  in    determination   of  re- 
fractive errors  of  the  eye,  453 
objections  to,  as  a  means  of  measuring 
refraction,  453,  454 
Optic  atrophy,  403 

nerve,  diagram  of,  57,  59 
thalamus,  16,  20,  23-28 
diagram  of,  23 
effects  of  lesions  of,  25-28 
pulvinar  of,  25 
subdivisions  of  23-25 
transverse  vertical  section  of,  27 
tract,  its  relations  to  internal  capsule,  30 
Orthophoria,  142,  143 

Pachydermique,  cachexic,  601 
Pachymeningitis,  287 

differential  diagnosis  of,  289 

etiology  of  288 

morbid  anatomy  of,  287 

prognosis  of  29l 

symptoms  of,  288,  345 

treatment  of,  291,  292 

varieties  of  287,  288,  290 
spinalis,  415-423 


774 


INDEX. 


Pachymeningitis      spinalis,     varieties     of, 

symptoms  of,  41fi,  417,  419,  420 
Pain,  impressions,  cortical  area  of,  15 
its  clinical  significance,  109 
its  relation  to  spinal  diseases,  91 
spinal,  its  clinical  significance,  93 
Painful  points,  electrical  treatment  of,  692, 

698 
Palate,  a  guide  in  diagnosis,  154 

in  facial  paralysis,  85 
Palm,  flattening  of  381 
Paralysis  agitans,  161,  586-591 
diagnosis  of,  589,  590 

from  cerebral  sclerosis,  333 
etiology  of,  587 
gait  of,  163,  164,  588 
morbid  anatomy  of,  586,  587 
prognosis  of,  590 
symptoms  of,  587,  588 

table  of  498 
treatment  of  590 
Paralysis,  alcoholic,  575,  576 
bulbar,  85,  86,  378 

facial  expression  of,  384,  385 
complete,  53 
crossed,  53 

of  olfactory  type,  80 
electricity  in,  719,  720 
facial,  crossed,  74,  75 
from  arsenic,  571,  572 

cortical  cerebral  lesions,  49,  284 

lead,  568 

non-cortical  cerebral  lesions,  284 

phosphorus,  572 
hysterical,  facial  expression  in,  170 

gait  of  165 
Kussmaul-Landry's,  442 
labio-glosso-pharyngeal,  85 
motor,  degrees  of,  l77 

rules  of  electrical  treatment  in,  720 

tests  for,  171,  176-179 
of  abducens  nerve,  83 
of  Bell,  85 

of  face,  from  cerebral  hemorrhage,  276 
of  motion,  clinical  significance  of,  48,  49 
of  motor  oculi  nerve,  82 

from  cerebral  hemorrhage,  275  276 
of  the  insane,  336 
of  trigeminus  nerve,  83,  84 
of  trochlear  nerve,  83 
pseudo-hypertrophic,  characteristic  at- 
titude of  167,  168 

gait  of,  164 
sensory,    from    intra-cerebral    hemor- 
rhage, 272 

its  clinical  significance,  53-60 
spastic,  357 

gait  of  163 
spinal,  91,  93,  94 

infantile,  369 

of  adults,  acute,  369 
trigeminal,  crossed,  75 


Paralj'tic  dementia,  152 
Para]ihasia,  16,  63,  66,  234 
Paraplegia,  86,  353 

cervical,  177 

gait  of,  162,  163 

tetanoid,  gait  of,  163 
Paresis,  electricity  in,  719,  720 

of  eye-muscles,  122 
Parkinson's  disease.  586 
Patellar  reflex,  abolition  of  403 
Patient,  acqirired  diseases  of,  113,  114 

age  of,  value  of  in  diagnosis,  110 

features  of,  117-119 

habits  of,  113 

occupation  of,  113 

sex  of,  importance  of  noting,  112 
Pearl  tumors,  340 
Perimyelitis,  429 
Permanent  battery,  643-645 
Peroneal  reflex,  96 

test  for,  173 
Petit  raal,  478 
Phosphorus-paralj^sis,  572 
Pia  mater,  inflammation  of  (see  meningitis) 
Piesmeter,  199 

Pinniform  decussation  of  sensory  tracts,  45 
Pistol-electrode,  Morton's,  674 
Plantar  reflex,  96 
Plate  machine  of  Ramsden,  648 
Plumbism,  567-571 

diagnosis  of,  569,  570 

etiology  of,  567 

morbid  anatomy  of,  567 

prognosis  of  570 

symptoms  of  567-569 

treatment  of,  570,  571 
Polarity  changer,  636 
Polarized  cell,  646 
Polar  method,  186 
Poliomyelitis  anterior,  365 
diagnosis  of,  372 
etiology  of  368,  369 
morbid  anatomy  of,  366,  367 
prognosis  of,  374 
symptoms  of,  369-372 

table  of  426 
treatment  of  374,  375 
varieties  of  368-372 

infantile  variety,  368 

photographs  of,  366-370 

sym]itoms  of,  table  of,  565 
Polyuria,  509 

Pons  varolii,  decussation  of  facial  nerve  iu 
36 

effects  of  lesions  of,  36,  74 

fibres  of  33 

gray  substance  of  33 

its  construction  and  functions,  33-37 

reticular  formation  of  35 

transverse  section  of,  36 
Posterior  longitudinal  bundle,  35 
Postero-lateral  spinal  sclerosis,  591-598 


INDEX. 


775 


I 


Postero -lateral  spinal  sclerosis,  differential 
diagnosis  of,  595-597 

morbid  anatomy  of,  591,  592 

symptoms  of,  592-594 

treatment  of,  598 
Post-hemiplegic  contracture,  270 
Post-paralytic  rigidity,  electricity  in,  715 

tremor,  333 
Potential,  high  and  low,  613,  614 
Primary  current,  612 

lateral  sclerosis  (see  lateral  spinal  scle- 
rosis). 
Principles  of  static  induction,  651-655 
Prisms,  their  indications  and  uses,  458,  459 
Progressive  muscular  atrophy,  372,  379-388 

deformities  of,  382-385 

diagnosis  of,  384 

diagrams  of,  380 

etiology  of,  380 

gait  of,  165 

morbid  anatomy  of,  379,  380 

prognosis  of,  386,  387 

symptoms  of,  380-384 

treatment  of,  387,  388 
Psammoma,  340 

Pseudo-hypertrophic   paralysis,    373.   388- 
390 

attitude  of,  388,  389 

diagnosis  of,  390 

etiology  of,  388 

gait  of,  389 

morbid  anatomy  of,  388 

prognosis  of,  390 

symptoms  of,  388-390 

treatment  of,  390 
Ptosis,  82. 

Pulvinar  of  the  optic  thalamus,  25.  27 
Pupil,  Argyll  Robertson's,  93 

contraction  of  120 

dilatation  of  120,  121 

hemiopic  reaction  of,  83,  121 

in  lesions  of  pons,  75 

rigidity  of,  403 

Robertson's,  tests  for,  120 
Pyramidal  tracts,  42 

diagram  of,  45,  58 

in  crus  cerebri,  31 

in  pons  varolii,  33 

of  brain,  28-30,  36 

Rachialgia,  508 

Ramsden's  plate  machine,  648 

Ranney's    improvement      on     the     Holtz 

machine,  657-661 
Reaction  of  degeneration,  189,  190 
Reflex,  abdominal,  96,  171 

ankle,  96 

cremasteric,  96,  171 

epigastric,  96,  172 

foot,  96 

gluteal,  171 

patellar,  96 


Reflex,  peroneal,  96,  173 
plantar,  96,  171 
pupillary,  176 
rectal,  174 
scapular,  96,  172 
sexual,  175,  176 
vesical,  174 
Reflexes,  a  guide  to  the  spinal  segments,  172 
deep,  96 

organic;  174—176 
skin,  171,  172 

diminution  of,  174 
spinal,  170-176 

abolition  of,  96,  174 
clinical  deductions  respecting,  174 
deep,  96 

exaggeration'  of,  96 
in  connection  with  incoordination, 
96 
tendon,  172,  173,  182 

exaggeration  of,  174 
Relative  resistance  of  living  tissues,  616 
Remak's  method,  685 
Resistance  of  galvanic  cell,  615 
Respiration,  Cheyne-Stokes,  86 
Restiform  body,  37 
Retarded  sensory  impulses,  91 
Reticular  formation  of  pons  varolii,  35 
Rheophores,  636 
Rheostat,  631,  632 

description  of,  631,  632 
employment  of,    in  galvanic  applica- 
tions, 681,  682 
fluid,  of  H.  L.  Bailey,  632 
use  of,  632 
Robertson's  pupil,  208 
tests  for,  120 

Sand-tumors  of  brain,  340 
Saturnine-poisoning  (see  plumbism) 
Scapular  reflex,  96 
Scirrhus  of  brain,  339 
Sclerosis,    cerebro-spinal,  facial   expression 
in,  170 
cerebro-spinal,  gait  of,  165 
spinal,  334 
Secondary  degeneration,  267 

lateral  sclerosis  (see  lateral  spinal  scle- 
rosis) 
Senile  meningitis,  297 
Sensation,  delayed,  206 

of  pain  and  temperature,  tests  for,  206, 

207 
of  touch,  pain,  and  temperature,  corti- 
cal centres  of,  15 
Sensory  area  of  cerebral  cortex,  15 

nerve-tracts,    electricity    in    disorders 

affecting,  724-728 
phenomena,  abnormal,  352-354 

their  clinical  significance,  93 
tracts,  42 

of  brain,  28,  30,  36 


776 


INDEX. 


Sex,  its  clinical  relations,  112 

Shaking  palsy,  586 

Sick-headache   from    eye-defect,    126,    128, 

129  (see  migraine) 
Si^men's  and  Halske's  cell,  625 
Sight,  its  relations  to  occipital  cortex,  15 

views  of  Ferrier,  Munk,  and  others,  15 
Sinuses  of  brain,  diagram  of,  225,  226 
Skin,  angioneuroses  of,  729 
electrical  tests  of,  199 
reflexes,  95,  96,  171,  172 
tests  for  tactile  sensibility  of,  199-201 
Smee's  cell,  623 
Smell,  abolition  of,  79 
Sneezing,  electricity  in,  724 
Spasm,  a  symptom  of  spinal  disease,  96 
effects  of  electrical  treatment  of,  721 
of  spinal  origin,  96,  171 
static  electricity  in,  721 
Spasmodic  atfections,  electricity  in,  720-721 
asthma,  electricity  in,  723 
tabes,  357-359 
Spastic  paralysis,  357 
Special  electro-therapeutics,  712 

senses,   impairment  of,  from   cerebral 
hemorrhage,  273,  274 
in  cortical  disease,  70 
tests  for,  207-209 
Speech,  Broca's  centre  of,  15,  16 

cortical   area  of  motor   impulses  con- 
cerned in,  15,  16 
diagram  of  mechanism  of,  67 
disorders  of  60-68 

from  lesions  of  the  pons,  75 
Speech-tract,  67,  75 

of  brain,  28,  30,  36 
Spinal  affections,  electricity  in,  717 
anaemia,  447 

diagnosis  of  447 
etiology  of,  447 
morbid  anatomy  of,  447 
prognosis  of,  447 
symptoms  of,  447 
treatment  of,  447.  448 
apoplexy,  diagnosis  of,  426 
etiology  of  425 
morbid  anatomy  of,  425 
prognosis  of  426,  427 
symptoms  of  425,  426 

table  of,  426 
treatment  of,  427 
automatism,  101 
commissures,  89 

conducting  tracts,  diagram  of,  87,  92 
congestion,  444-447 

diagnosis  of.  445,  446 
etiology  of  444,  445 
morbid  anatomy  of,  444 
prognosis  of  446 
symptoms  of  445 
treatment  of  446 
contracture,  94,  96 


Spinal  cord,  anterior  columns  of,  sclerosis  of 
357 
anterior  horns  of,  89,  95 

inflammation    of    (see   polif 
myelitis  anterior) 
congenital  abnormalities  of  350 
construction  of,  diagram  of,  350, 

351 
descending  degeneration  of,  88 
diseases  ot,  349 

table  of,  350 
effects  of  complete  division  of,  95 
lesions  oi^  86-97 
pressure  u[ion,  95 
focal  lesions  of,  349,  350,  408-44S 
functional  diseases  of,  350, 434-448 
grav  matter  of,  functions  of,  table 
oX  355,  356 

f;roups  of  fibres  in,  349-352 
esions  of  guides  in  diagnosis  of, 
356,  357 
gray  matter  of,  93 
motor  cells  of  88 

columns  of,  88 
non-systematic    lesions    of,    349. 

408-448 
posterior   columns  of  sclerosis  of 

(see  locomotor  ataxia) 
reflex  arcs  of,  diagram  of,  95 
sensory  columns  of  88,  91 
summary  of  100,  101 
systematic  lesions  of,  349,  350 
trophic  cells  of,  88,  91 
tumors  of,  423,  424 
unilateral  lesions  of  95 

diagram  of,  391 
vascular  lesions  of  350 
visceral  disturbances  in  diseases  of 

94 
•white  matter  of,  functions  of,  table 
of,  355 
degeneration,  secondary,   diagram    of 

354 
diseases,  faradization  in,  718 

galvanic  current  in,  717,  718 
s^'mptoms  of,  table  of  353 
grav  matter,  diagram  of,  94 
hemiplegia,  285.  286,  414 
hemorrhage,  425 
irritation,  435 

etiology  of,  435, 
symptoms  of  435 
treatment  of,  435 
lateral  sclerosis  (primary  variety),  359- 
361 
diagnosis  of,  361 
symptoms  of,  360,  361 
leptomeningitis,  svmptoms  of,  table  of 

422 
meningeal  hemorrhage,  427,  428 
etiology  of  427 
morbid  anatomv  of,  427 


INDEX. 


777 


Spinal    meningeal    hemorrhage,   prognosis 
of,  427,  428 
s\Mnntoia.s  of,  427 
table  of,  42fi 
treatment  of,  428 
meningitis,  415-423 

diagnosis  of,  404,  420-422 
etiology  of,  418 
morbid  anatomy  of,  416-418 
prognosis  of,  421 
symptoms  of,  418-420 
treatment  of,  42 L,  42.J 
varieties  of,  41H-418 
nerve- roots,  350,  351 

effects  of  lesion  of,  91 
nerve-tracts,  diagram  of,  47,  58 
neuralgias,  symptoms  of,  table  of,  549 
pachymeningitis,   symptoms   of,    table 

of,  422 
pain,  93 

reflexes,  89,  94,  9(1  170-176 
abolition  of,  352 
exaggeration  of,  352,  353 
superficial,  95 
sclerosis,  334 

of  anterior  columns,  357 
postero-laLeral,  591-598 
segments,  88,  89 

architecture     and      functions    of, 

tables  of,  355,  356 
diagrams  of,  89,  90,  92 
tumors,  423,  424 

diagnosis  of,  421 
etiology  of  424 
morbid  anatomy  of,  423 
prognosis  of,  424 
symptoms  of,  424 
treatment  of  421 
Sponge  electrodes,   reasons  for  removal  of 

sponge,  639 
Spurious  hydrocephalus,  310 
Squint,    its  relation  to  refractive  errors  of 

the  eye,  453 
Statical  electro-therapeutics,  702-711 
Static  breeze,  670-672 

electricity,  612,  613,  647-675 

compared  with  galvanism,  655 
electro-motive  force  of,  655 
general  rules  for  use  of,  708-711 
in  chorea,  722 
in  medicine,  655-661 
in  spasm,  721 
indications  for,  705,  706 
internal  resistance  of,  655 
methods  of  application  of,  665-675 
•modifying  effects  of,  687 
physiology  of  therapeutical  action 

of  706-708 
quantity  of,  655 
induced  current,  672-675 
induction,  principles  of,  651-655 
insulation,  670 


Static  machine  (see  frictional  machine) 
care  of,  661-6(55 
charging  of,  664 
improvements  in,  656 
length  of  spark,  660 
quantity  of,  656 
outfit,  661 
shock,  668,  669 
Stevens'  method  for  the  detection  and  cor- 
rection of  anomalies  of  the   visual 
apparatus,  axioms  relating  to,  452- 
461 
operation,  460 
Strabismus,  121 

its  clinical  importance  contrasted  with 
insufficiency,  467,  468 
Strumous  diathesis,  119 
Subacute  cerebral  meningitis,  299 
Substantia  nigra,  31 

cells  of,  32 
Symptoms,  general,  duration  of,  clinical  sig- 
nificance of,  110 
exciting  causes  of,  110,  111 
revealed   by   clinical    history    of   the 

patient,  108-116 
revealed  by  the  sense  of  sight  during 

a  clinical  examination,  116-170 
revealed  by  various  tests,  170-213 
Syncope,  symptoms  of,  table  of,  480 
Syringomyelia,  433,  434 
diagnosis  of,  434 
etiology  of,  433 
morbid  anatomy  of,  433 
prognosis  of,  434 
symptoms  of,  433,  434 

Tabes  dorsalis,  gait  of,  164  (see  locomotor 

ataxia) 
Tabes,  spasmodic,  357-359 
Tache  cerebral,  307 

Tactile  sensibility,  normal,  table  of,  201 
Taste,  disturbances  of,  with  facial  paralysis, 
85 
tests  for,  209,  210 
Tegmentum  cruris,  31 

effects  of  lesions  of,  33 
Teeth,  a  guide  in  diagnosis,  153,  154 

defects  of,  as  a  cause  of  epilepsy,  464 
Temperature   impressions,  cortical  area  of, 
15 
modifications   of,    in   cerebral    hemor- 
rhage, 274,  275 
Tendon  reflexes,  96 
Terminal  labile  stimulation,  685 
Tests,  electric,  171,  185-187 
electrical,  185-199 

summary  of,  194,  195 
employed  in  diagnosis,  170-213 
for  associating  tracts  of  cerebrum,  184 
for  commissiiral  fibres  of  cerebrum,  184 
for  incoordination  of  movement,  179- 
181 


778 


INDEX. 


Tests  for  irritability  of  the  muscles,  171 ,  182, 
183 

for  motor  paral^-sis,  171,  176-182 

for    reflex    excitability    of    the    spinal 
cord,  170-17H 

for  sensory  nerves,  171 

for  tactile  sense,  199-202 

for  vision  and  ocular  movements,  133- 
150 
Tetanoid  paraplegia,  357 
Tetanus,  diagnosis  of,  584 

electricity  in,  721 

etiology  of,  581 

facial  expression  of,  155,  583 

prognosis  of,  584,  585 

symptoms  of,  582,  583 
table  of,   422 

treatment  of,  585 

varieties  of,  582 
Tetany,  437-440 

diagnosis  of,  439 

etiology  of,  438 

morbid  anatomy  of,  438 

prognosis  of,  439,  440 

symptoms  of,  438,  439 

treatment  of,  440 
Therapeutical  action  of  electrical  currents, 

655,  656 
Thermo-electric     differential     calorimeter, 

632,  633 
Thermometry,  cerebral,  study  of,  633 
Thomsen's  disease,  440-442 

diagnosis  of,  442 

etiology  of,  440 

morbid  anatomy  of,  440,  441 

symptoms  of,  441,  442 

treatment  of,  442 
Thrombosis  of  cerebral  capillaries,  228,  229 

of  cerebral  sinuses,  223-226 
Toepler  machine,  650 
Tongue,  a  guide  in  diagnosis,  153, 154 

loss  of  power  of  protrusion  of,  78 
Torticollis,  electricity  in,  723 
Touch-impressions,  cortical  area  of,  15 
Touch,  its  disturbances,  clinical  significance 

of,  91 
Tract,  fronto-central,  184 

hippocampo-temporo-central,  184 

hippocampo-temporo-frontal,  184 

occipito-central  184, 

occipito-temporal,  184 

temporo-central,  184 

temporo-frontal,  184 
Tremor,  alcoholic,  574 

etiology  of,  586 


Tremor,  in  cerebral  diseases,  72 

of  cerebral  origin,  331 

post-paralytic,  333 
Trejihining,  guides  for,  49-51 
Trismus,  581 

neonatorum,  582 
Trophic  disorders,  electricity  in,  726 

disturbances,  353 
Trouve's  cells,  624 
Trousseau's  test,  438 
Tubercular  tumors  of  brain,  338,  339 
Tumors  of  brain,  218 

etiology  of  341 
varieties  of,  338-341 

of  the  brain  and  its  envelopes,  337 
Tiirck's  method,  19 
Two-fluid  cells  of  galvanism,  625-627 

Ulnar  paralysis,  157,  158 
Units,  electrical,  table  of,  617 
Upjier  limb,  cortical  area  of,  50 
Uraemia,  symptoms  of,  table  of,  480 

Vaginismus,  509 

Vasomotor,  and  trophic  disturbances  from 

cerebral  hemorrhage,  277,  278 
centres  of  the  medulla,  86 
system,  diseases  of,  electricity  in,  728- 

729 
Vermis,  lesions  of,  symptoms  of,  76 
Vertebral  caries,  symyitoms  of  table  of,  549 
Visceral  functions,  their  dependence  upon 

the  nerve-centres,  466 
Vision,  tests  for  defects  of,  133-135 
Visual  field,  145 
Volt,  618 

Voltaism  (see  galvanic  current) 
Vomiting,  86 
Von    Marum's  modification   of  Ramsden's 

machine,  648 
Voss  machine,  650 

Walker's  cell,  623 
Watt,  618 

Will-tract  of  cerebrum,  28-30 
Woollv  hand,  161 
Word-blindness,  65,  66,  234-236 
Word-deafness,  64,  65,  234-236 
Wrist-drop,  159,  160,  385 
Writer's  cramp,  436,  437 

etiology  of,  436 

morbid  anatomy  of,  437 

symptoms  of,  436,  437 

treatment  of,  437 
Wry-neck,  electricity  in,  723 


3  2  6  8     1 


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